DSM Disorders in Children

1. DSM Disorders in Children ADHD + Behavioural Disorders

2. Classical Conditioning • Pavlov • Dog is presented with meat powder to make it salivate • Meat powder = Unconditioned Stimulus (UCS) • Salivation = Unconditioned Response (UCR) • A bell is rung before UCS is presented • Bell = Neutral Stimulus (NS) • Repetition leads to salivation on hearing the bell before any meat powder is presented • Bell = Conditioned Stimulus (CS) • Salivation = Conditioned Response (CR)

3. Classical Conditioning • Little Albert • Rat is presented to 11 month old boy who plays with it happily • Rat = Neutral Stimulus (NS) • Loud steel bar is struck behind Albert’s head after presenting with rat • Loud noise = Unconditioned Stimulus (UCS) • Fear = Unconditioned Response (UCR) • After 5 times, Albert shows extreme fear on presentation of the rat • Rat = Conditioned Stimulus (CS)

4. Behaviourism • Behaviourism is the study of learning • i.e. Observable behaviour • Law of Effect: • Behaviour that is followed by consequences satisfying to the organism will be repeated, and behaviour that is followed by unpleasant consequences will be discouraged

5. Operant Conditioning • Behaviour operates on the environment. • All behaviour, internal or external, can be explained by the environmental consequences it produces • “Stimulus-Response” becomes “Response-Consequence” Freedom of choice is a myth and all behaviour is determined by the reinforcers provided by the environment

6. Behaviourism • Reinforcement • Positive Reinforcement • Strengthening a tendency to respond in anticipation of a pleasant event (reinforcer) • Negative Reinforcement • Strengthens a response by removing an aversive event • Modeling – e.g. sharing, aggression, fear. • Punishment • Can lead to anxious responses, or be taken as a reinforcer if followed by a reinforcer • E.g. Child may seek punishment or abuse because the guilty parent may follow it with love

7. Behavioural Therapy • Extinction: Fading out of conditioned response through appropriate reinforcement • Counterconditioning: Eliciting a new response to a stimulus, using positive reinforcers • Systematic Desensitization: • 1. Deep muscle relaxation • Gradual exposure • Aversive conditioning: Pairing an attractive stimulus with an unpleasant event

8. Skinner (1948) The Superstitious Pigeon Eight pigeons received reward every 15 seconds • One bird conditioned to turn counter-clockwise • One repeatedly thrust its head into the upper corner of the cage • Pendulum motion “dance” • Incomplete pecking movements • Reinforcement interval increased to one minute • Movements became more energetic • Extinction • Took up to 10,000 responses before extinction occurred in one case

9. Skinner (1948) • Non-contingent reinforcement • Behaviour is accidentally reinforced leading to a belief in a causal relationship between behaviour and reward • A relationship does still exist between the reward and the subject • Can produce a feeling of strength and control, reduce anxiety, improve performance

10. Locus of Control • As a child develops, behaviours are learned which are followed by some form of reinforcement • Reinforcement increases child’s expectancy that behaviour will produce desired reinforcement • External locus of control • Interpreting consequence as controlled by luck, fate or powerful others • Internal locus of control • Interpreting ones own behaviour and personality as responsible for consequences

11. Applied Behaviour Analysis • Improves level of functioning in Mental Retardation, learning Disabilities and Autism • Target behaviour is reinforced in small levels (e.g. Eating – picking up spoon, scooping food, moving spoon to mouth, remove with lips etc) • Inappropriate and self-injurious behaviour is reduced (e.g. rocking, swaying, aggression) • Can bring children with severe cases of Autism to basic levels of social functioning by age 7.

12. http://www.youtube.com/watch?v=I_ctJqjlrHA • http://www.youtube.com/watch?v=gbH_jpYlYew • http://www.youtube.com/watch?v=hulVH9jpR8k • http://www.youtube.com/watch?v=PPWL5yimhyg

13. Stage 3: 18 months – 4 years • Security in seperateness allows the child to experiment with their own volition • Conscious self begins to emerge  development of the ego • Beginning of control of impulses  delayed gratification • Development of language

14. Stage 3: Language • Sub-units of behaviour (stimulus-response/response-consequence) are organised into patterns/sets  Cause & Effect according with environment • Exploration of environment begins formation of cognitive map • Operant units store in cognitive maps • Associated with neural learning networks (enhanced with stimulation)

15. Stage 3: Operant Units A - B - C word picture object Association of arbitrary units C - A Object word Backward association Most important evolutionary leap in development of human language which is apparently unique to the human

16. Stage 3: Language • Primary language - images and emotions • Cognitive language develops from associations of arbitrary units, not only by direct teaching • Early associations will be more general, • e.g. “Dog” may become the word for any external object, or any black object • “Dada” may refer to all males • Psychological associations become more complex, arising in logical thought • Memory as we know it may correspond with the development of language, hence people “not remembering” their early years

17. Stage 3: Will • As identity separates into an individual unit, the child develops the power to choose their own actions • Action-Consequence • I am what I do • Good-bad associations with self (pleasure/ guilt) are controlled by the inner executive (central executive functions) • The right to act in awareness of punishment and obedience • E.g. the hot stove

18. Stage 3: Trauma • Improperly restricting the child may result in decreasing will, thus decreasing spontaneity and confidence • May cause stunting of inner authority – the right to be free

19. Stage 3: Comparative models • Erikson: Autonomy vs shame and guilt • Reich/Lowen: Masochist (Endurer) structure • Psychopath challenger-defender

20. Stage 3: Comparative models • Piaget: Preoperational • Increase in speed of movement and thought • Symbolic thought and language development • “Magic” thought • Animism (living objects) • Egocentric world-view

21. Stage 3: Comparative models • Freud: Anal stage • Toilet training: obsession with the erogenous zone of the anus with retention or expulsion of feces • Social pressures put on internal pleasure • Stubbornness or malicious excretion • Anal expulsive character: messy, disorganised, careless and defiant • Anal retentive character: neat, precise, orderly, careful, with-holding, passive-aggressive • Possession and attitudes towards authority

22. Freud Freud did not reach his discoveries through a clearly defined scientific methodology Careful observations of patients over decades of clinical analysis Many Freudian theories cannot be tested scientifically Many are proven to be unreliable

23. Freudian Personality Structure • Id • Basic biological urges – hunger, thirst, sexual impulse • Pleasure principle • Immediate gratification, regardless of reason, logic, safety or morality • Constantly seeks expression • Operates at an unconscious level • Eros and Thanatos

24. Freudian Theory • Ego • Limits and controls the impulses of the id • Reality Principle • Alert to the real world (conscious) and the consequences of behaviour • Satisfies id’s urges using rational means which are reasonably safe and socially acceptable

25. Freudian Theory • Superego • Limits the ego to moral and ethical internalised rules between good and bad. • Instilled by your parents (locus of control) • Conscience – controls with guilt • Operates on both conscious and unconscious levels

26. Freudian Theory The ego tries to balance the needs and urges of the id with the moral requirements of the superego Psychopathology is an imbalance or malfunction, usually if the demands of the id are too strong to be controlled Anxiety arises with fear – free-floating anxiety causing the onset of defense mechanisms

27. Defense Mechanisms • Psychological mechanisms to protect against anxiety • Self-deceiving and reality-distorting • Repression • Regression • Projection • Reaction Formation • Sublimation

28. Defense Mechanisms • Repression • Forcing disturbing thoughts out of consciousness • Anxiety associated with “forbidden” thoughts is avoided – usually sexual desires • Hidden conflicts may be revealed through slips of the tongue, dreams, psychoanalysis, free association or hypnosis • Psychological problems can arise in the form of neuroses

29. Defense Mechanisms • Regression • Ego guards against anxiety by causing the person to retreat to the behaviour of an earlier stage of development • Earlier speech patterns, childlike behaviour • Mid-life crises • Going home to mother when there is a marriage problem

30. Defense Mechanisms • Projection • Unconscious urges are noted in other people’s behaviour • Externalising anxiety-provoking feelings to reduce anxiety • E.g. Husband feeling impulses of being unfaithful may project his desires onto his wife by becoming insanely jealous and angry • Projections are truly believed

31. Defense Mechanisms • Reaction Formation • “The Lady doth protest too much, me thinks” • Engages in behaviours that are the exact opposite of the id’s real urges • Exaggerated or obsessive • Complete rejection blocks anxiety • E.g. homophobia – gay bashing

32. Defense Mechanisms • Sublimation • Finding socially acceptable ways of discharging energy that is the result of unconscious forbidden desires • Necessary for a productive and healthy life • Through evolution of civilisation, humans sublimate their primitive biological impulses

33. Freudian Theory • Ramachandran (1995) examined a neuropsychological cause of repression in paralysed patients • Patients who are paralysed on one half of their body who show repression • Always choose impossible two-handed tasks instead of one-handed tasks • Show no disappointment when they fail • Vestibular irrigation brought back repressed feelings in some patients

34. Freudian Theory • Homophobia • Homophobics more aroused by homosexual stimulus than non-homophobics • Under-report their arousal • Anna Freud and others have written extensively on Freudian theory and focused it into scientifically testable areas

35. Attention Deficit: difficulty sitting still (e.g. class/meals) Hyperactivity: unable to stop moving or talking Description: - Disorganised, erratic, tactless, obstinate and bossy - Difficulty getting along with peers and establishing friendships - (in part due to: ) aggressiveness, annoying and intrusive behaviours - different social goals (e.g. sensation seeking over team-work) - Miss social cues (may recognise social cues in cognitive exercises but not in actuality) 3 – 7% of school-age children worldwide Attention Deficit/Hyperactivity Disorder

36. 15 – 30% of children with ADHD have a learning disability in math, reading or spelling Often put in special education because of difficulty with classroom environment Overlap of 30-90% between ADHD and Conduct Disorder ADHD is associated with earlier age of onset of Conduct Disorder symptoms Attention Deficit/Hyperactivity Disorder

37. 30% of ADHD diagnoses comorbid with internalizing disorders (e.g. Depression and anxiety) 65-80% of children with ADHD still meet criteria for the disorder in adolescence. Up to 50% of children meet the criteria in adulthood (Rates vary depending on method of assessment) Attention Deficit/Hyperactivity Disorder

38. Predominately Inattentive type • Predominately Hyperactive-Impulsive type • Combined type Diagnosis of ADHD

39. Genetics: • Heritability estimates as high as 70-80% • 50% of children from ADHD parents are likely to have it • Genetic evidence associated with Dopamine neurotransmitter • Neurobiology: • Frontal Lobe Dysfunction: - Lobes are under-responsive, under-sized. - Cerebral blood flow is reduced • Tobacco/Nicotine: - Environmental toxins, food additives, Lead poisoning - Low birth weight and maternal coldness Etiology of ADHD

40. Psychology: • Parent-Child relationships: - Commanding, negative parents AND less compliant, negative kids - Child behaviour has a negative effect on parents’ behaviour Etiology of ADHD

41. Stimulant Medications: - Methylphenidate (MPH) e.g. Ritalin, Adderall - Reduce disruptive behaviour - Improve concentration and goal-directed activity in 75% of cases - 80% of 11 million prescriptions between 1996-2000 were for children diagnosed with ADHD (problems with diagnosis?) - Side-effects: loss of appetite, sadness, headaches, stomach aches Treatment of ADHD

42. Psychological Treatment - Behavioural conditioning (point systems, reward charts, etc) Combinations most effective cross-culturally Treatment of ADHD

43. Description: - Aggression and cruelty toward people or animals, damaging property, lying and stealing - Callousness, viciousness, lack of remorse  Adult antisocial personality disorder 4-16% of boys, 1.2-9% of girls Behaviour peaks at 17 and reduces in young adulthood Conduct Disorder(Including Oppositional Defiant Disorder)

44. Life-course Persistent form: shows problems from age 3 into adulthood Adolescent limited 15-45% comorbidity with Anxiety and Depression Most likely to occur with parent of low verbal intelligence or antisocial personality disorder Conduct Disorder

45. Genetic: • Vague and mixed • MAOA gene – Monoamine Oximade enzyme metabolizes neurotransmitters. • Children who have low MAOA activity AND are maltreated are more likely to develop conduct disorder Etiology of Conduct Disorder

46. Neurobiological • Poor verbal skills • Executive functioning (self-control, planning) • Memory problems Etiology of Conduct Disorder

47. Psychological • “Moral Awareness” • Guilt, altruism • Physical abuse • Reinforcers • Agression reinforced by achieving a goal • Interpretation of ambiguous acts as aggressive • Peer groups • Harsh and inconsistent parental discipline • Sociocultural factors – educational facilities, family life, neighbourhoods etc Etiology of Conduct Disorder

48. Parental Management Training (PMT) • Multisystemic Treatment • Family, school, community and peers • Cognitive therapy • Anger management, etc. Treatment of Conduct Disorder