Final Flashcards
1
Q
According to the U.S. Child Abuse Prevention and Treatment Act, what’s child maltreatment?
A
Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or
emotional harm, sexual abuse, or exploitation, or an act or failure to act, which presents an imminent risk of serious harm to a child
2
Q
What’s physical abuse?
A
- Punching, beating, kicking, burning, shaking, or otherwise physically harming a child
- Often unintentional and resulting from severe physical punishment
3
Q
What’s neglect?
A
- Child’s basic needs are not being met
- Different types of neglect: physical, educational, emotional
4
Q
What’s physical neglect?
A
- Failure to provide for a child’s basic physical needs
- Ex: refusal of or delay in seeking health care, inadequate provision of food, abandonment, expulsion from the home or refusal to allow a runaway to return home, inadequate supervision, and inadequate provision of clean clothes
5
Q
What’s educational neglect?
A
- Failure to provide for a child’s basic educational needs
- Ex: allowing chronic nonattendance, failing to enroll a child of mandatory school age in school, and failing to attend to a special educational need
6
Q
What’s emotional neglect?
A
- Failure to provide for a child’s basic emotional needs
- Ex: marked inattention to the child’s needs for affection, refusal of or failure to provide needed psychological care, spousal abuse in the child’s presence, and permission for drug or alcohol use by the child
7
Q
What’s sexual abuse?
A
- Abusive acts that are sexual in nature
- Ex: touching genitals, intercourse, exhibitionism, production of pornographic photos
8
Q
What’s emotional abuse?
A
Repeated acts by parents or caregivers that could or have caused serious behavioral, cognitive, emotional or mental disorders
9
Q
What are the challenges of studying the incidence and prevalence of child abuse?
A
- People may not be willing to report this
- Relies on identified cases
- Retrospective report (ex: asking adults what happened to them 10-15 yrs ago as a child)
10
Q
What are the one-year incidence rates of child abuse?
A
- US = 12.1/1000 children
- Canada = 9.7/1000 children
- Explanation: US has higher rates of poverty and it’s much harder to get access to adequate + affordable health care
11
Q
In an anonymous survey, what percentage of parents report using forms of physical punishment that constitute child abuse (ex: hitting the child with an object)?
A
Responding anonymously, 10% of parents report using forms of physical punishment that constitute child abuse (ex: hitting the child with an object)
12
Q
Studies and treatment of child maltreatment have focused on what kind of abuse?
A
Physical and sexual abuse
13
Q
What’s the most commonly reported/most prevalent type of child maltreatment?
A
Neglect
14
Q
What are some age characteristics linked with child maltreatment?
A
- Younger children are more likely to be neglected
- Older children (> 12 years) are more likely to be sexually abused
15
Q
What are some gender characteristics linked with child maltreatment?
A
Girls are more likely to be sexually abused
16
Q
What are some family characteristics linked with child maltreatment?
A
- Single-parent families have higher rates of physical abuse and neglect
- Having a single-parent is a risk factor
17
Q
What are some SES characteristics linked with child maltreatment?
A
- Poverty = risk factor
- Lots of overlap with poverty
18
Q
Describe the findings of Bullinger et al., (2022) study on upward social mobility and child maltreatment
A
- Upward social mobility: moving up the social ladder
- Study found that in countries where children had more chance of upward social mobility, there were lower rates of childhood maltreatment, independent from income inequality and poverty
- Upward Social Mobility = Protective -> lower risk for child maltreatment if child is more likely to move up social/income ladder later on
- Points to reducing income inequality as a means to reduce childhood maltreatment
- Maybe something that leads to childhood maltreatment is stress due to lack of resources
19
Q
What were Park & Walsh (2022) findings on how COVID-19 impacted childhood maltreatment?
A
- Seems to be evidence for notable increases in childhood maltreatment during lockdowns
- Effect occurs across the globe
- Effect was stronger in low and middle income countries (LMIC)
- This is in line with poverty as a risk factor
- Countries with more poverty were more negatively impacted during the lockdown, in terms of childhood maltreatment
- COVID is a chronosystem influence (Bronfenbrenner model)
20
Q
What’s the developmental course of maltreatment?
A
- Children experiencing maltreatment must learn to cope with challenges in environment -> learning how to update schemas on people and the world
- These adaptations may cause problems in other contexts
21
Q
What does maltreatment shape/alter?
A
- Brain development: impacts brain structure (ex: smaller brain volume) and function
- Physiological reactivity to stress
- Understanding of emotion
22
Q
How does maltreatment shape a child’s understanding of emotion?
A
- Being abused or neglected by a parent exposes a child to different emotional experiences
- May change their understanding and experience of emotions
- Ex: if constantly exposed to anger from a parent, and if recognizing that anger was adaptive, would that change the child’s perception of emotion? -> child may become always on the lookout for anger to protect self
- Early experience of maltreatment fundamentally changes how children perceive emotions
- Children who have been physically abused show a bias for identifying angry faces and need less info to identify angry faces
- Implications for their behavior and emotional response
23
Q
Describe Pollak et al. (2000) study on Child Maltreatment & Understanding of Emotion with the emotion recognition task
A
- Participants: 17 physically abused children, 16 physically neglected children, 15 children with no abuse history
- Between 3 and 5 yrs old
- Emotion recognition task
- Children presented with 25 vignettes describing a protagonist experiencing 1 of 5 emotions: happiness, sadness, disgust, fear, anger
- Ex: Johnny’s/Susie’s little brother broke his/her favourite toy on purpose
- After each story, the child was shown 3 photos of emotions and one was correct (matched the emotion in vignette) and 2 were distractors
- Asked the kids to point to the face that matched the emotion in the vignette
24
Q
What were Pollak et al. (2000) trying to identify with their study on Child Maltreatment & Understanding of Emotion with the emotion recognition task
A
1) Sensitivity to differences between facial expressions
* How accurate is the child?
* Number of times a child picks “angry” correctly
* Some of these will be lucky guesses -> subtract the number of times child says “angry” incorrectly
2) Bias towards labeling a particular stimulus as a particular emotion
* Extent to which a particular label may be more likely than others
25
Describe the findings for Pollak et al. (2000) study on Child Maltreatment & Understanding of Emotion with the emotion recognition task
1) Sensitivity to differences between facial expressions
* Found that neglected children were less sensitive to differences between facial expressions -> didn't do as good of a job of differentiating than other children
* Maybe neglect is leading to some difficulties with identifying emotions
2) Bias towards labeling a particular stimulus as a particular emotion
* Extent to which a particular label may be more likely than others
* Physically abused children show a bias for angry faces (even if the story wasn't related to anger)
* Neglected children show a bias for sad faces
26
What are 2 possible reasons for Pollak et al. (2000) findings for their study on Child Maltreatment & Understanding of Emotion with the emotion recognition task
1) Visually, children can't discriminate between the faces
2) They have different understandings of the emotional displays
27
Describe Pollak et al. (2000) follow-up study on Child Maltreatment & Understanding of Emotion with the emotion discrimination task
Participants:
* 13 physically abused children
* 15 physically neglected children
* 11 children with no abuse history
* Between 3 and 5 yrs old
* Emotion discrimination task:
* Shown 2 photographs of models showing emotions and asked children if “same or different”
28
Describe the findings for Pollak et al. (2000) follow-up study on Child Maltreatment & Understanding of Emotion with the emotion discrimination task
- Found no differences between 3 groups on this task -> they were all able to identify different emotions in this task
- It's not that physically abused and neglected children can't visually see the differences in emotions (goes against hypothesis 1 from original study)
29
Describe Pollak et al. (2000) follow-up study on Child Maltreatment & Understanding of Emotion with the emotion differentiation task
* Children shown photographs of 2 models and asked to rate the similarity of the facial expressions (emotions)
* 6 shelves lined up horizontally
* One photograph of angry face placed on the far right
* Child indicated similarity by placing the other photo
30
Describe the findings for Pollak et al. (2000) follow-up study on Child Maltreatment & Understanding of Emotion with the emotion differentiation task
- Found that neglected children perceived less distinction between angry, sad, fearful facial expressions
- Found that physically abused children and control children perceived more distinction between anger and other negative emotions
- Conclusions: experience of maltreatment changes understanding of emotion (it's not about recognition but about understanding how similar or distinct emotions are to each other)
- Role of experience in learning emotions (we learn emotion signals through interactions with others in early childhood)
31
Describe Pollak & Sinha (2002) study on Child Maltreatment & Understanding of Emotion
Participants
* 8-10 yrs old
* 24 physically abused children
* 23 non-maltreated children
* Presented children with photos displaying angry, sad, fearful, and happy facial images
* Showed children heavily pixelized images of emotions
* Images are slowly filled in randomly, so that the expression gradually appears
* Dependent variable is how early the child can identify the photo
* Measured how early children can correctly identify the emotion as they slowly depixelize it
* At 3.3 second intervals, more of photo filled in
* At each interval, children were prompted to identify the emotion
* Had to rate their confidence in their choice from 1 (Guess) to 5 (Certainty)
* Only correct responses with a rating of 4 or 5 were used -> didn't count guess responses (ex: 1 ratings)
32
Describe Pollak & Sinha (2002) findings for their study on Child Maltreatment & Understanding of Emotion
- Found no significant difference in how quickly/accurately all children identified happy and fearful faces
- Found a difference in identification of angry faces
- Children who have experienced physical abuse are more likely to recognize angry faces earlier than other children (differences start at image 7) and needed less info to accurately identify angry faces than control children
- Children who experienced physical abuse were slower than control children to identifying sad faces and needed more info than control children to identify sad faces
33
How do Diathesis-Stress Models explain the connection between child maltreatment and psychopathology?
* Genetic predispositions interacting with maltreatment to lead to later psychopathology
* If you have a greater diathesis/greater vulnerability, it increases your likelihood for later psychopathology
34
Describe Caspi et al. (2002) findings for their diathesis-stress model study of conduct disorder
- Found that in children with conduct disorder, MAOA activity interacts with maltreatment
- Low MAOA activity and maltreatment predicts antisocial behavior in adulthood
35
Describe Caspi et al. (2003) findings for their diathesis-stress model study of depression
* Looked at depression and the serotonin transporter gene 5-HTTLPR
* 2 versions of this transporter gene: short allele and a long allele
* In adults, short allele is associated with increased depression, but only for those who experience significant life stress
* Diathesis = short allele
* Stress = life stress
* Life stress moderates the relationship between this gene and depression
* Looked at the probability of a major depression episode in participants with 2 copies of long alleles, with 1 short and 1 long allele, and with 2 copies of short alleles, who had experienced no maltreatment, probable maltreatment and severe maltreatment
* At no levels of maltreatment, it doesn’t matter what gene you have (no differences)
* At probable maltreatment, we start to see differences in genes
* At severe maltreatment, we see significant differences in genes (probability highest for s/s, then s/l, and lowest for l/l)
36
Describe the findings of a second study that replicated the Caspi et al. (2003) findings for their diathesis-stress model study of depression
* Found that social support played a protective role
* The moderator was itself moderated by something else -> the relationship was further moderated based on levels of social support
* Maltreated children with a short allele and poor social support had rates of depression 2x higher than maltreated children with a short allele and social support
37
Describe Bleys et al. (2018) meta-analysis of studies on the interaction between life stress and the serotonin transporter gene
* Saw that a number of studies didn't find the interaction between life stress and the serotonin transporter gene
* So conducted a meta-analysis of 51 studies, with total of 51,449 participants
* Found evidence for small but significant interaction between 5-HTTPLR serotonin transporter gene moderating relation between life stress and depression
* Research still ongoing
38
Is child maltreatment characterized by multifinality or equifinality?
* Multifinality
* Maltreatment is a risk factor for the development of many forms of psychopathology
* Ex: depression, antisocial behavior, PTSD
* Different diatheses can lead to different outcomes -> diatheses may shape the type of psychopathology that youth who experience maltreatment develop
* Not all childhood maltreatment leads to PTSD
39
What characterizes exposure to a PTSD Criterion A stressor?
* Actual or threatened death, serious injury, sexual violation
* Direct experience
* Witness it in person
* Learns that it happened to a close family member or friend (must have been violent)
* Experiences repeated exposure to details of event (vicarious trauma)
* Doesn't apply to exposure through electronic media, tv, movies, or pictures, unless this exposure is work related
* Ex: first responders, jury members
40
What do you need to be diagnosed with PTSD?
- Need exposure to a Criterion A stressor/trauma
- In one or more methods of exposure
41
Recent scholarship has been expanding the definition of Criterion A Trauma to include what?
* Exposure to racial discrimination
* Recent scholarship acknowledging consistent experienced and vicarious exposure to racism as experiences of trauma
* Recent review of meta-analyses shows discrimination has stronger impact on youth mental health outcomes than traumatic experiences/maltreatment such as neglect
42
What are the 4 core features of PTSD?
* Intrusion (1 symptom required)
* Avoidance (1 symptom required)
* Extreme arousal (2 symptoms required)
* Negative cognitions and mood (2 symptoms required)
* Symptoms must persist for at least one month
43
What are the symptoms related to the intrusion core feature of PTSD?
- Recurrent, involuntary, memories (may see this in children as play episodes)
- Flashbacks
- Nightmares
- Intense physical distress to reminders of the events
- Marked physiological reactivity to stressor
44
What are the symptoms related to the avoidance core feature of PTSD?
* Avoiding thoughts or feelings related to the trauma
* Avoiding stimuli related to the trauma (ex: place related to trauma)
45
What are the symptoms related to the extreme (physiological) arousal core feature of PTSD?
- Sleep disturbance: difficulty falling or staying asleep
- Irritable/aggressive behavior (can be manifested as tantrums for children)
- Hypervigiliance
- Easily startled
- Difficulty concentrating
- Self-destructive behavior (not present in children below 6)
46
What are the symptoms related to the negative cognitions and mood core feature of PTSD?
- Inability to recall key features of the event
- Persistent negative beliefs about self or world
- Distorted blame of self or others
- Persistent negative trauma related emotions (ex: horror, shame)
- Diminished in activities
- Alienation from others
- Inability to experience positive emotions
47
What are some other PTSD symptoms that we don't see within the 4 core features?
* Derealization: phenomenon where everything takes a dream-like quality
* Depersonalization: feeling of being outside of own body
Ex: people report floating above themselves and watching themselves experience this trauma
48
Describe PTSD in Children 6 Years of Age & Younger
* Presence of one or more symptoms of intrusion
* One or more symptoms of avoidance and/or negative cognitions -> combined the negative cognitions/mood and avoidance
* 2 or more symptoms of extreme arousal
* Symptoms may be expressed through play (reenactment)
* More behaviourally anchored symptoms:
* “Feelings of detachment or estrangement from others” = social withdrawal
* “Persistent inability to experience positive emotions” = persistent reduction in expression of positive emotions -> not as engaged and active as you would expect a young kid to be
* Irritability expanded to include tantrums
49
What's the prevalence of Post Traumatic Stress Disorder?
* Limited data with children
* With adolescents:
* National Comorbidity Survey of Adolescents -> lifetime prevalence of PTSD is 5%
* Other work has suggested that the majority of youth who experience trauma experience some symptoms of PTSD -> exposure to criterion A stressors is generally associated to some symptoms of PTSD
* 85% of youth who experienced a significant trauma reported at least one symptom of PTSD
50
Trauma- and stressor-related disorders was a new category in which edition of the DSM?
Trauma- and stressor-related disorders is a new category in DSM-5
51
What disorders does the trauma- and stressor-related disorders category in the DSM-5 include?
* Acute Stress Disorder
* Adjustment Disorder
* Post Traumatic Stress Disorder (PTSD)
* Reactive Attachment Disorder
* Disinhibited Social Engagement Disorder
52
Describe Acute Stress Disorder
* The development during or within 1 month after exposure to an extreme traumatic stressor of at least 9 symptoms associated with intrusion, negative mood, dissociation, avoidance, and arousal
* Meeting criteria for PTSD but it hasn't been a month yet
* Immediate/short-term symptoms of PTSD in response to trauma exposure but hasn't been long enough for diagnosis of PTSD
* If symptoms persist overtime, the diagnosis may change into PTSD
53
Children who react to more common (and less severe) forms of stress in an unusual or disproportionate manner may qualify for a diagnosis of what disorder?
Adjustment disorder
54
What are the DSM-5 criteria for Reactive Attachment Disorder?
A) A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by 2 related symptoms
B) A persistent social and emotional disturbance characterized by at least 2 of 3 related symptoms
C) The child has experienced a pattern in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by at least one of 3 related symptoms
D) The care in Criterion C is presumed to be responsible for the disturbed behaviour in Criterion A (ex: the disturbances in Criterion A began following the lack of adequate care in Criterion C)
E) The criteria are not met for autism spectrum disorder
F) The disturbance is evident before 5 years of age
G) The child has a developmental age of at least 9 months (no matter how old a child is, they need to have the intellectual/cognitive types of functioning at the level of a 9 month old)
55
What are the symptoms related to Criterion A of Reactive Attachment Disorder?
A) A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
1. The child rarely or minimally seeks comfort when distressed
2. The child rarely or minimally responds to comfort when distressed
56
What are the symptoms related to Criterion B of Reactive Attachment Disorder?
B) A persistent social and emotional disturbance characterized by at least 2 of the following:
1. Minimal social and emotional responsiveness to others
2. Limited positive affect (low in surgency)
3. Episodes of unexplained irritability, sadness or fearfulness that are evident even during nonthreatening interactions with adult caregivers (odd emotional outbursts in inappropriate situations)
57
What are the symptoms related to Criterion C of Reactive Attachment Disorder?
C) The child has experienced a pattern in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults
2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (ex: frequent changes in foster care)
3. Rearing in unusual settings that severely limit opportunities to form selective attachments (ex: institutions with high child-to-caregiver ratios)
58
What are the specifiers for Reactive Attachment Disorder?
Specify if:
- Persistent: the disorder has been present for more than 12 months
Specify if:
- Severe: when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels
59
What are the DSM-5 criteria for Disinhibited Social Engagement Disorder?
A) A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of 4 related symptoms
B) The behaviors in Criterion A are not limited to impulsivity (as in attention- deficit/hyperactivity disorder) but include socially disinhibited behaviour
C) The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of 5 related symptoms
60
What are the symptoms related to Criterion A for Disinhibited Social Engagement Disorder?
A) A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following:
1. Reduced or absent reticence in approaching and interacting with unfamiliar adults
2. Overly familiar verbal or physical behavior (that's not consistent with culturally sanctioned and age-appropriate social boundaries)
3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings
4. Willingness to go off with an unfamiliar adult with minimal or no hesitation
61
What are the symptoms related to Criterion C for Disinhibited Social Engagement Disorder?
C) The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults
2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (ex: frequent changes in foster care)
3. Rearing in unusual settings that severely limit opportunities to form selective attachments (ex: institutions with high child-to-caregiver ratios)
4. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (ex: the disturbances in Criterion A began following the lack of adequate care in Criterion C)
5. The child has a developmental age of at least 9 months
62
What are the specifiers for Disinhibited Social Engagement Disorder?
Specify if:
- Persistent: the disorder has been present for more than 12 months
Specify if:
- Severe: when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels
63
What does Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) consist of?
* How CBT can be applied to symptoms of trauma
* Changing cognitions around traumatic event
* Psychoeducation
* Cognitive techniques
* Relaxation skills
* Safety skills
* Graded exposure (involves creating a very detailed trauma narrative around experience of trauma, exposing self to past traumatic experience through the creative recounting of event, may do specific exposure around trauma cues)
64
Describe Cohen et al. (2004) study on TF-CBT for Child Sexual Abuse
Participants
– 2 sites
– 229 youths enrolled
– ages 8-14
– 79% female
– PTSD symptoms (89% diagnosed with PTSD)
– 90% experienced many traumas
Design
– Random assignment
– TF-CBT vs Child-centered therapy (CCT) -> both have strong theoretical basis and are widely used
– Groups were comparable on PTSD diagnoses
– Treated for 12 weeks
– Mean number of sessions completed was same for each group (~10)
– 7 therapists were trained in both treatment modalities and administered both
65
What's child-centered therapy?
- Focuses on establishing a trusting relationship with the therapist
- Encourages parents and children to structure treatment (decide when and how to address the trauma)
- Therapist provides active listening and empathy, and encourages parents and children to develop strategies for coping with what happened
66
Describe Cohen et al. (2004) findings for their study on TF-CBT for Child Sexual Abuse
- In both treatment groups, children and parents improved on most outcomes
- Compared to CCT, children receiving TF-CBT demonstrated a lot of positive effects
- They also demonstrated greater diagnostic recovery (after TF-CBT treatment ~21% of children still met criteria for PTSD and 46% in CCT treatment still met criteria for PTSD)
67
What are the positive effects that children receiving TF-CBT demonstrated in Cohen et al. (2004) study
Child effects
– Fewer PTSD symptoms
– Less shame
– Less depression
– Fewer total problems
– Greater trust
Parent effects
– Less parent depression
– Less self-blame
– More support of child
– Better parenting in general
68
Describe McGuire et al. (2021) systematic review of TF-CBT among preschool-aged children
* TF-CBT in children and adolescents is ‘level 1’/’well established’ to be efficacious -> highest level of evidence
* Reviewed 11 studies (mix of RCTs, case studies, single group designs)
* TF-CBT with pre-school aged children = ‘level 2’/’probably efficacious'
* Not enough research among preschool kids
* Promising evidence, both RCTs worked better than TAU/control, but specific implementations of TF-CBT were too different from each other for the treatment to be considered ‘well-established'
* Overall wasn't enough evidence that TF-CBT was very effective in pre-school aged children
69
What are other common therapies for trauma (other than TF-CBT)?
* Cognitive Processing Therapy (CPT)
- Involves creating + repeatedly reviewing narrative
- Adapting unhelpful beliefs about the trauma
- Doesn’t involve family as much
* Prolonged Exposure Therapy (PE)
70
Describe Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
* Treatment that's been developed for children with PTSD that has the strongest evidence base to date
* Involves both the parent and the child
* Has multiple components:
* 1st component: psychoeducation
○ Learning what are normal trauma responses
○ Learning about common experiences for others experiencing a similar thing
○ Understanding trauma triggers and the behaviours that they elicit
* 2nd component: skills building (relaxation & safety skills)
○ Developing skills to cope with extreme anxiety
○ Relaxation training, thought-stopping techniques
○ Parents learning skills for how to manage child when they get irritable, oppositional, or refuse to sleep
* 3rd component: trauma narrative (graded exposure)
○ Revisiting of the trauma
○ Telling the story of trauma and cognitions and thoughts that go with it
○ Working against avoidance
○ How you make sense of things that happen to you affects how you feel about yourself -> cognitions affect emotions
○ Can be done through writing a story, cartoons or drawings
○ Trauma narrative is shared with a caregiver -> helps the parent and child communicate about the child's trauma
* Looking at cognitions and making sense of them
* TF-CBT has been found to lead to reduction in PTSD symptoms and behavioural symptoms which is maintained overtime
* Since TF-CBT has been implemented in the state of Connecticut, the number of kids in child protective services system needing inpatient psychiatric care has gone down enormously (from 65% to 30%)
71
What's a manic episode?
- A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary)
- During the period of mood disturbance, 3 (or more) of related symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree
72
What are the symptoms related to a manic episode?
- Inflated self-esteem or grandiosity
- Decreased need for sleep (ex: feels rested after only 3 hrs of sleep + all-nighters)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility (attention too easily drawn to unimportant or irrelevant external stimuli)
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
- Excessive involvement in pleasurable activities that have a high potential for painful consequences (ex: sexual behavior, shopping, gambling)
73
What's a hypomanic episode?
- Same as manic episode (especially in terms of symptoms) except:
- Lasting at least 4 consecutive days (shorter duration)
- Represents a change in functioning for the person
- No marked impairment in social or occupational functioning
- Less extreme manic episode
74
What's Bipolar 1?
- Manic episode (has had a full manic episode)
- May or may not show depression
- Specifier: with mixed features (experiencing symptoms that include both mania and depression at the same time)
75
What's Bipolar 2?
- Major depressive episodes and hypomanic episodes
- Has never had a full manic episode
- Specifier: with mixed features (experiencing symptoms that include both hypomania and depression at the same time)
76
What's Cyclothymia?
- Period lasting at least 1 year (in children and adolescents, 2 years for adults) with numerous hypomanic and depressive symptoms that do not meet full criteria for either a hypomanic, manic, or major depressive episode
- Cycling of inflated to deflated mood
- In lower range
77
Is it possible to move from bipolar 1 to bipolar 2?
No, once you have a manic episode you can't be diagnosed with bipolar 2
78
Describe the history of bipolar disorder in children
- Between 1990 and 2000 diagnoses of bipolar disorder in children quadrupled
- 1999 saw the publication of a book entitled the Bipolar Child by a New York psychiatrist
- Argued that bipolar disorder in children was overlooked
- Provided a vague and general list of behaviors
- In 2001, field decided that bipolar disorder could be diagnosed in children
- Noted that there can be differences in presentation of bipolar in children and adults
79
What did the vague and general list of bipolar disorder behaviours in children provided by author of the Bipolar Child consist of?
- Poor handwriting
- Complains of being bored
- Is very intuitive or very creative
- Excessively distressed when separated from family
- Has difficulty arising in the A.M
- Elated or silly, giddy mood states
- Curses viciously in anger
- Intolerant of delays
80
What are the differences in presentation of bipolar in children and adults?
- Adults typically have discrete episodes (easily see the start and finish of episodes -> may have very clear episode of mania and very clear episode of MDD)
- In children, may see changes in mood even within the same day (don't see discrete episodes)
- Tend to have long episodes like this (1-4 yrs)
81
What's the narrow phenotype of bipolar disorder?
- More conservative
- “Classic” adult symptoms (ex: mania, grandiosity)
- Some children/adolescents meet full diagnostic criteria meant for adults
- Issues with lack of diagnosis (missing diagnosis for children with pediatric bipolar)
82
What's the broader phenotype of bipolar disorder?
- More liberal
- More inclusive
- Irritability, mood lability (mood swings)
- Irritability is much more common than mania
- Irritability is not a specific symptom for bipolar -> occurs in other disorders as well (ex: Depression & ODD)
- Issues with specificity -> may get false positives (may diagnose people without this disorder)
83
What are some diagnostic challenges with paediatric bipolar disorder?
- Irritability, rather than euphoria, can be the predominant mood state
- Issues with differential diagnosis (ex: Depression, ODD, CD, ADHD may all manifest as or include irritability)
- Due to this overlap, some authors have argued that to be diagnosed with bipolar disorder, children must show core features of mania (ex: grandiosity, elevated mood), which has higher specificity
- Children may not show discrete episodes of mania
-> may show rapid mood changes within shorter periods of time and even within the same day
- These all make it hard to conceptualize bipolar disorder in children
84
What did the Practice Parameters of the American Academy of Child and Adolescent Psychiatry state paediatric bipolar should consist of?
- They stated that DSM criteria for adults should be applied to children and adolescents
- Mania, which may include irritability, needs to present as a marked change in the individual’s state (someone that's irritable all the time can't get a diagnosis of bipolar disorder -> irritability has to come episodically or cycle rapidly and demonstrate a difference from the child's baseline)
- Diagnostic validity of bipolar disorder in preschool children has yet to be established -> don’t have good guidelines for diagnosing it in preschool-aged children
85
What are some DSM-5 concerns about paediatric bipolar disorder?
- Concerns about over-diagnosing bipolar disorder in childhood
- Lots of children show frequent severe tantrums and chronic irritability -> these may not be specific to bipolar disorder, may be part of other disorders
- This all led to DMDD diagnosis
86
What's the prevalence & course of Bipolar Disorder?
- Very rare prior to puberty -> rates rises in adolescence
- NCS-A estimates lifetime prevalence of Bipolar I/Bipolar II at 2.9%
- ~60% of people with bipolar I or II experience their first episode in adolescence (prior to 19 yrs old)
- Peak onset of bipolar disorder -> between 15-19 yrs old
- Most report that their first episode was a major depressive episode and then manic or hypomanic episodes might come later
- Mania in adolescence associated with psychosis, mixed episodes (mania/depression), extreme and severe mood lability (mood swings)
87
Describe the course of bipolar disorder
- 40% - 100% of children and adolescents with bipolar disorder will recover within a year
- 60% - 70% of the children who recover will show recurrence within a year
- Bipolar disorder -> episodes coming and going
- Recovery rates differ based on age of onset
88
What's recovery with Bipolar Disorder?
8 consecutive weeks in which an individual doesn't meet DSM criteria for manic episode, hypomanic episode, depressive episode, or mixed episode
89
Describe how recovery rates differ based on age of onset for bipolar disorder
* Tend to find that children with a pre-pubertal onset of bipolar disorder are 2x less likely to recover from a manic, depressive or hypomanic episode compared to those who don't have the initial onset of bipolar disorder until adolescence
* Pre-pubertal onset of bipolar disorder is a risk factor for poor recovery and a more severe and chronic course of bipolar disorder through lifetime
* Children with early-onset manic episodes are 13 - 44x more likely to have manic episodes in adulthood
* Childhood onset of mania is a risk factor for continuing to have manic episodes throughout adulthood -> homotypic continuity: stability in symptom presentation across time
90
Describe the comorbidity of paediatric bipolar disorder
ADHD
- 60% - 90% of children and 30% of adolescents with bipolar meet criteria for ADHD
- Possible that stimulant medications may exacerbate bipolar symptoms
Disruptive behavior disorders (ex: ODD & CD)
- 20% of children with bipolar disorder meet criteria for conduct
disorder
- Overlap in symptoms -> especially irritability
- Conduct symptoms may be a consequence of bipolar presentation (manic episodes might lead one to engage in conduct-related behaviours)
91
What are some clinical correlates in paediatric bipolar disorder?
- Associated with marked social impairment in different domains
Peers:
- Poor social skills
- Frequently teased and victimized by peers
- Fewer friends
Families:
- Poor relationships with siblings
- Frequent hostility and conflict with parents
92
Describe the genetics of bipolar disorder
- Work with adults suggests that bipolar is highly heritable/genetically based (has over 75% genetic contribution)
- Twin studies: if one identical twin has bipolar disorder, there's a 65% chance that the other twin will have it as well
- Twin studies suggest that variability is not entirely due to genetics
- Genetics appear to play a bigger role in early onset cases
- If one parent or both parents have bipolar disorder, there's a 5x greater chance that the child will develop either bipolar disorder or another mood disorder (ex: depression)
- Multiple gene problem: many different genes might be playing together and be implicated in bipolar disorder -> can't isolate bipolar disorder to only 1 or 2 genes
93
Describe the Etiology & Maintenance of Bipolar Disorder
- Environmental factors likely play a role
- Problematic family interactions (ex: hostility, conflict)
- Contributes to expression of bipolar symptoms
- Diathesis-stress model: genetic risk and environmental stressor
- Passive gene-environment correlation: parents are genetically passing on their genes that might increase risk for bipolar disorder but these parents might also be raising their children in an environment that can contribute to the symptom presentation of bipolar disorder
94
What are the different medications used to treat Bipolar Disorder?
- Mood stabilizers
- Antipsychotics
- Anti-depressants
95
Describe mood stabilizers as a medication treatment for bipolar disorder
- Lithium
- Common treatment for adult bipolar disorder
- Approved for use in children aged 12 and older with bipolar disorder
- Serious side effects (ex: toxicity)
- Difference between effective dose of lithium that leads to reductions in symptoms and toxic dose that is bad for the body is relatively small
- Having toxic levels of lithium in the bloodstream can be associated with kidney problems, hypothyroidism and significant weight gain
- Compliance with instructions is very important
- Have to visit physician regularly to monitor side effects
96
Describe Amerio et al. (2018) meta-analysis on lithium
* Meta-analysis of 12 RCTs of lithium use for youth with bipolar disorder
* Found that lithium was safe in the short-term, probably due to good levels of monitoring in the RCTS
* Found that the side effects were fairly mild (ex: GI issues, headaches and only small minority experienced hypothyroidism)
* When compliance and monitoring is good, lithium can be a safe and effective short-term option for youth with bipolar disorders
97
Describe atypical antipsychotics as a medication treatment for bipolar disorder
- Wide-ranging class of antipsychotics
- Ex: Asenapine Maleate (Saphris), Clozapine (Clozaril), Iloperidone (Fanapt), Lurasidone (Latuda), Olanzapine (Zyprexa)
- 10 RCTs have demonstrated that these medications are effective for treatment of bipolar disorder in youth
- Generally these atypical antipsychotics have been shown to be effective for the treatment of bipolar disorder in youth -> reduction in manic and hypomanic symptoms similar to lithium
98
Describe anti-depressants as a medication treatment for bipolar disorder
- For Bipolar I and II, the depressive symptoms and episodes can be chronic and severe -> mood stabilizer/antipsychotics may not help with that
- Can that be treated with anti-depressant medication?
- Potential for bipolar switch -> adolescents who have bipolar disorder who are treated with antidepressant medication alone were more likely to experience a manic episode, than those treated with an atypical antipsychotic
- SSRIs may cause the onset of a manic episode
- Research is mixed -> some research with adults has suggested that antidepressants were not associated with inducing mania but the follow-up was very short-term in many of these studies
- Antidepressants may be best prescribed in combination with an atypical antipsychotic or lithium -> SSRIs are not often recommended by themselves in youth with bipolar disorder
99
Describe the medication treatment approach for paediatric bipolar disorder
- Medication is the first line treatment -> the initial option in a lot of cases
- Pharmacotherapy is indicated for nearly all youth with bipolar disorder
- However, many will not receive medication and many may be treated with the wrong medication (ex: an antidepressant by itself)
100
What's the general recommendation for treating mania in youth?
- Begin with one atypical antipsychotic
- If patient doesn't respond, or can't tolerate the drug, taper, and then try a second
atypical antipsychotic
- If patient doesn't respond to 2 or 3 atypical antipsychotics, switch to lithium
- If patient partly responded to antipsychotic, add lithium
- And then depending on the level of depressive symptoms, maybe the psychiatrist would consider adding an SSRI
101
What are some reasons why some youth may take the psychosocial treatment route for paediatric bipolar disorder?
- May be poor compliance to medication regimes that could be a major source of relapse and worsening of symptoms
- Potential toxicity of lithium
102
What are the psychosocial treatments offered for paediatric bipolar disorder?
Family Education:
- Helping the family understand the disorder and the symptoms
- Reducing conflict in the family
- Medication management
103
RCTs have shown support for what 2 family treatments for paediatric bipolar disorder?
1) Multifamily Psychoeducational Psychotherapy
2) Family-focused therapy
- Both of these family therapies focus on education, communication and problem-solving skills
- In both studies, participants who received family therapy showed an improvement in mood symptoms compared to those who did not
104
What's the RAINBOW acronym for Child- and Family-Focused CBT for youth with bipolar disorder
Routine
- Establish a predictable routine that will reduce tantrums, negativity, conflict
Affect regulation
I can do it!
- Increase children’s and parents’ beliefs that they can manage bipolar symptoms (increase self-efficacy)
No negative thoughts
- Retraining cognitive distortions associated with depression
Be a good friend and balanced lifestyle
- Helping teach social skills to facilitate social support and positive social interactions
Oh, how can we solve this problem?
- Help parents and children learn to problem-solve together
Ways to get support
- Help parents learn how to seek help, as well as advocate for their child at school
105
Describe West et al. (2014) study on CFF-CBT for Pediatric Bipolar Disorder
- 69 children (7 - 13 yrs old) diagnosed with bipolar disorder
- Inclusion criteria: stabilized on medication (needed this to be in the trial) -> still symptomatic, but not in acute distress
- Randomized to:
- CFF-CBT (individual therapy) or TAU (treatment as usual) -> assigned a therapist (not trained in CFF-CBT) in the same clinic
- Looked at parent report of mania and depression and clinician report of depression
106
Describe West et al. (2014) findings for their study on CFF-CBT for Pediatric Bipolar Disorder
- At post-treatment, youth in CBT group had lower mania symptoms than youth in control group
- 88% of youth in CBT group were below the clinical cutoff for manic symptoms, at post-treatment, compared to 21% in the control group
- Saw similar pattern for parent-reported depression
- No difference for clinician-reported depression
- Positive evidence for efficacy of CFF-CBT -> not only for mania symptoms but also potentially for depressive symptoms as well
107
According to Caspi et al. (2018) what does psychiatric comorbidity look like?
- Psychiatric comorbidity is ubiquitous
- 66% of people with one disorder have another disorder
- 53% of people with 2 disorders have another disorder
- 41% of people with 3 disorders have another disorder
- Comorbidity is the norm
- Anxiety & depression are most comorbid and schizophrenia & bipolar disorder are most comorbid
- Then, schizophrenia and anxiety are also highly comorbid
108
Are risk factors for psychopathology specific or nonspecific?
- Risk factors are largely nonspecific
- Multifinality
- Best example: childhood maltreatment = risk for almost every form of mental disorder
- Low SES has been a risk for almost every childhood disorder -> low SES is a proxy variable for other things (ex: lack of access to quality education and healthcare, poorer living conditions, lack of food, etc.)
- Problems with behavioral inhibition -> externalizing disorders, anxiety disorder
- Genetic risk can be specific to disorder and a general risk across disorders
109
Describe Pettersson et al. (2016) study on genetic risk factors for psychopathology
- N: All adults in Sweden (3.4 million)
- National registry data
- Found that genetic risk is specific and general
- Genes specific to disorder vs general genetic risk across disorders
- Many disorders have a lot of variation explained by general genetic things
- Most genetic things are predicting psychopathology as a whole -> not one specific disorder
110
Describe Caspi et al. (2018) findings for the lack of specificity in predictors
- Lots of risk factors associated with general psychopathology
- A lot of factors predict just having a disorder vs not having a disorder
- Some factors increase risk for specific dimensions of psychopathology and general psychopathology
- A lot of factors predict having internalizing or externalizing disorders
- Mostly just predicting having a psychological disorder
111
What's homotypic continuity?
Disorder predicts itself over time
112
What's heterotypic continuity?
- Disorder predicts other things over time
- Common in psychopathology
- Having a disorder predicts occurrence of different disorders across time and development
113
Describe the heredity of psychopathology and parental psychopathology as a risk factor
- Parents pass on risk for any anxiety disorder, not necessarily a specific anxiety disorder or the anxiety disorder they have
- Parents pass on risk for a broader ASD phenotype
- Certain disorders may run in families (ex: bipolar), but psychopathology (having any psychological disorder) seems to run in families more often
114
Describe Caspi et al. (2020) study on the progression of disorders throughout development
* Uses the Dunedin study
* Looking at how people with psychopathology change or stay the same overtime
* Before age 18, many people hadn't had a diagnosis yet
* After age 45, less than 10% of people haven’t been diagnosed
* Lots of people have a disorder at one time and switch disorders at another time
115
Describe the hierarchical dimensional model for psychopathology
○ Growing evidence supporting that psychopathology is dimensional in nature
○ Psychopathology conceptualized along a series of dimensions
○ Symptoms, syndromes & spectra are continuous
○ Empirically/quantitatively defined
○ Hierarchically-organised spectra and syndromes
○ Comorbidity represented by higher-order dimensions
116
What's the p factor?
- Term for theoretical construct
- Broadly defined, represents what is common to all psychological disorders
- Theories that it represents a general vulnerability for psychopathology
- P-factor is causing all of these psychological disorders
- P causes one to be higher or lower on a number of dimensional pathologies
- P is empirically based -> a result of statistical modelling and analysis, not directly observed
- Therefore, we interpret what it means
- Understanding and quantifying p isn't something we can observe -> have to do it statistically
117
What's the Correlated-Factors Model of psychopathology?
- Really common way of thinking about psychopathology
- Different domains are simply positively associated with each other
- Doesn't have any p
- Model says that internalizing disorders cause specific disorders and that these (internalizing, externalizing, and thought) are all related to each other
- Nothing explaining or causing them
118
What's the Hierarchical Model of psychopathology?
- Different domains of psychopathology (ex: int, ext, thought) cause specific disorders
- Higher-order factor causes different domains
- Higher order factor indirectly causes specific disorders (mediated through domains)
- Ex: P leads to more internalizing problems which leads to more depressive symptoms
- Ex: HiTOP model
119
Describe Ringwald et al. (2023) meta-analysis of HiTOP model
- 35 studies
- 120k participants
- 23 DSM diagnoses
- Found support for general psychopathology factor (p) causing internalizing and externalizing disorders but model looks a bit different from original HiTOP model
- Highlights how there are different ways of thinking about psychopathology
120
What's the Bifactor Model of psychopathology?
- Specific factors cause specific disorders
- General psychopathology (p) also directly causes disorders
- Model Caspi and Moffet’s research supports
121
What are the different theories of P?
* Dispositional negative emotionality
* Emotion regulation difficulties/impulsive responsivity to emotion
* Low cognitive functioning -> not just intelligence, also attention & concentration, processing speed, higher level thinking (lower levels of it)
* Thought dysfunction/aberrant thought processes -> thought problems and disturbances and abnormalities in thinking
* Underlying vulnerability to psychopathology -> p = diathesis
122
What are some challenges to p-factor?
- Symptom networks
- Common manifestation shared by disorders
- How does ASD fit in?
- Explaining disorders changes across studies
123
Describe the symptom networks challenge to p-factor
- Symptoms and disorders are just networks
- Symptoms across different disorders cause each other
- There's no underlying p or risk for general psychopathology that explains everything
- Implication: intervening on central symptom or disorder leads to domino effect of symptom reduction in related symptoms -> if it goes away, other disorders go away
124
Describe the common manifestation shared by disorders challenge to p-factor
- P might not be a cause of psychopathology, we might be assessing a common result of many forms of psychopathology
- Maybe P = impairment, which is core feature of many disorders
- Flipped arrows -> from disorder to P instead of other way around
125
Describe the ASD challenge to p-factor
* Article on p-factor by Ronald (2019) challenging P-factor research
* P-factor theory doesn't mesh well with our understanding of ASD
* ASD has:
* High homotypic continuity (endures over time)
* High comorbidity, but doesn't morph to other disorders
* ASD Is very specific
* Genetic risk for autism not associated with p (characterized by dysregulation) in 36-month olds (Miller et al., 2019)
126
Describe the "explaining disorders changes across studies" challenge to p-factor
- Watts et al. (2023) standardized factor loadings on general factors of psychopathology
- Shows that different studies find very different strengths of correlations between a disorder and P
- Wide range across every disorder
- Ex: panic disorder shows correlations between 0 & .80
- P doesn't always explain disorders equally
127
Describe the long-term implications of P for aging
* Using p to measure mortality and biological aging
* Psychiatric disorders are associated with physical health problems
* Psychological disorders are linked with poor health
* Intervening on p can reverse or slow cellular aging process
* This helps across all different levels of functioning
128
Describe the implications of P for psychotherapy
- If psychopathology has a common cause, can we have a common treatment?
- Transdiagnostic Treatment: treatment targeting underlying difficulties that occur across many disorders
- Ex: TF-CBT -> not an explicitly transdiagnostic treatment but has wide ranging impacts on child PTSD symptoms, internalizing, and externalizing symptoms
129
Describe the Unified Protocol for Transdiganostic Treatment of Emotional Disorders in Children and Adolescents
- AKA UPC and UPA
* Flexible, theoretically consistent and evidence-based interventions for youth with a wide array of emotional disorder presentations
* UPC = group therapy for children under 13
* UPA = individual therapy with adolescent clients
* Based on the adult unified protocol
* Incorporates effective cognitive behavioural strategies and acceptance and mindfulness strategies for youth
* Content in UPA and UPC:
○ Motivational enhancement and goal setting
○ Emotion education
○ Functional assessment of emotional behaviours
○ Opposite actions for emotional states that may be causing problematic emotional behaviours
○ Awareness of physical sensations (interoceptive exposure)
○ Cognitive component: cognitive reappraisal and problem solving
○ Awareness (present-moment awareness and non-judgmental awareness)
○ Situational exposure (ex: narrative exposure)
○ Typically ends with relapse prevention
* UPC has parent group content that goes along with child group content
* UPA has an optional parent module
130
Describe Carlucci et al. (2021) meta-analysis of UP-CA
- Meta-analysis of 19 RCTs 13 uncontrolled pre-post trials
- N children = 2183
- Found moderate to large effects across anxiety and depression -> didn't look at other outcomes
- Shown to be effective and work well across lots of different symptoms
- Found most evidence for internalizing symptoms
131
What's Modular Treatment?
- Transdiagnostic treatment
- Match-ADTC: modular treatment for Anxiety, Depression, Trauma, Conduct Problems
- Pick a starting point based on presenting problems, then follow the flowchart
132
Does P mean that
categories don’t exist or aren’t important?
No, P doesn't mean categories don’t exist or aren’t important, it means these categories have a common cause
