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  1. By

  2. Introduction to Childhood Mental Illness Review

  3. Paradigms in Psychopathology A Paradigm is a set of basic assumptions, a general perspective, that defines how to conceptualise and study a subject, how to gather and interpret relevant data Useful to organise our thinking • Genetics • Neuroscience • Psychodyamics • Cognitive Behaviourism • Diathesis-Stress

  4. Nature Vs Nurture • Stress • Relationships • Culture • Genetic coding • Genetic regultation and expression • Leads to Neurobiology and behaviour

  5. Genetics • Almost all behaviour is heritable to some degree • Genes do not operate independently from the environment - Gene-environment Interaction Environment can alter gene expression - Genes may predispose us to seek out certain environments that then increase our risk for developing a particular disorder Psychopathology is polygenic (not caused by one gene but rather the interaction of many)

  6. Genetics Psychopathology is polygenic (not caused by one gene but rather the interaction of many) Quantitative Genetics identifies specific DNA sequences responsible for genetic influence

  7. Neuroscience • Depression, anxiety, dementia and other psychopathologies all show associations with neurological dysfunction • Neuron: The neural cell, stimulated through a change in electrical potential to cause a nerve impulsewhich releases a chemical • Neurotransmitter: The chemical release to allow communication between neural synapses, usually generating an excitatory or an inhibitory signal

  8. Psychodynamics • Childhood experiences help shape adult personality • There are unconscious influences on behaviour • The causes and purposes of human behaviour are not always obvious Freud: Psychopathology results from unconscious conflict • Anecdotal evidence, not the scientific method Benefits of gameplay, maintenance of negative schema  internal cognitive processes

  9. Cognitive Behaviourism • Thorndike (1874-1949): Law of Effect Behaviour that is followed by consequences satisfying to the organism will be repeated, and behaviour that is followed by noxious or unpleasant consequences will be discouraged • Skinner (1904-1990): operant conditioning -Positive reinforcement -Negative reinforcement -Automatic reinforcement

  10. Cognitive Behavioural Therapy (CBT) • Restructuring a pattern of thought that is presumed to be causing a disturbed emotion or behaviour • Self-efficacy: a belief that one can achieve desired goals • Differing levels of extremity in treatment

  11. Diathesis-Stress: An Integrative Paradigm • Diathesis: Predisposition • Genetic • Neurobiological diathesis: - Oxygen deprivation at birth - Poor nutrition - Maternal viral infection - Smoking during pregnancy • Psychological Diathesis: - Sexual or physical abuse in childhood - Sociocultural influences (e.g. anorexia nervosa) - Other childhood experience  dysfunctional or destructive cognitive sets (e.g. hypnotizability)

  12. Diathesis-Stress • Stress: Noxious or unpleasant environmental stimulus that triggers psychopathology - Traumatic events: Death, divorce etc - Environmental Stress: Social Psychology • Diathesis-Stress models focus on interaction between predisposition towards disease and environmental/life disturbance

  13. Maslow’s Hierarchy of Needs

  14. Stage 1: Womb – 12 months • Motor Functions and security • Stage 2: 6 months – 2 years old • Mobility and emotion • Stage 3: 18 months – 4 years old • Will and action • Stage 4: 4 – 7 years old • Social Identity • Stage 5: 7 – 12 years old • Social contract • Stage 6: Adolescence • Reconstitution • Stage 7: Early Adulthood and Beyond • Self-knowledge

  15. Stage 1: Womb – 12 months • Formation of the physical body during prenatal development and infancy • Body growth is rapid at this stage • Motor operations: suck, eat, digest, grasp, crawl, stand, walk, manipulate objects, gravity • Little awareness of the outside world • Fused symbiosis with the mother • No separate sense of self • Awareness of survival and physical comfort

  16. Stage 1: Trauma • Trauma may result in fear, insecurity, confusion • Symptoms of disorganisation or depression • Feelings of insanity, excessive thinking • Little “grounding” – detachment from body and basic consensus reality structures • Anxiety in mundane tasks, hypervigilance (high responsiveness to stimuli and constant scanning of environment for threats) • Healthy development teaches security, focus, calm and vigilance

  17. Anxiety Disorders Specific Phobia Panic Disorder Separation Anxiety Disorder Generalised Anxiety Disorder Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder

  18. Common Etiology of Anxiety Disorders • Genetic vulnerability • Increased activity in the fear circuit of the brain (amygdala) • Decreased functioning of GABA and serotonin, increased norepinephrine activity • Behavioural Inhibition – agitation to new stimuli in infancy • Predictive to a 30% level of development of social anxiety • Neuroticism • Personality trait with a tendency to react with greater than average negative emotion • Twice as likely to develop into an Anxiety Disorder • Cognitive Factors (e.g. attention to cues of threat and low perception of control) • Negative Life events

  19. Major Depressive Disorder (MDD) • Diagnosis • MDD: Sad mood or loss of pleasure for 2 weeks, with at least 4 other symptoms, such as • Changes in sleep pattern • Change in appetite • Problems with attention • Feelings of worthlessness • Suicidality • Not just a single episode • Episodic Disorder: may be periodic, then clear • Subclinical depression can remain for years • Dysthymic Disorder (Dysthymia): Chronic depression for more than half the time for 2 years

  20. Bipolar Disorder • Bipolar I Disorder: “Manic Depressive Disorder” • Bipolar II Disorder • Cyclothymic Disorder (Cyclothymia) • Chronic mood disorders for at least 2 years • Mild alternative depression and mania • 1% Prevalence rate for BPI, 40,000 in Ireland • 4% for BPII and Cyclothymia

  21. Etiology of Mood Disorders • Neurobiology • Amygdala – elevated • Hippocampus – diminished • Prefrontal cortex – diminished • Anterior cingulate – diminished • Assessment of how emotionally important a stimulus is • Effective focus • Making plans based on emotionally relevant cues

  22. Etiology of Mood Disorders • Cortisol (Stress Hormone) • Hypothalamus-Pituitary-Adrenocortical Axis (HPA) • Signals transmitted from the Amygdala • E.g. Cushings Syndrome - Oversecretion of cortisol - Frequent depressive symptoms • Dexamethasone Supression Test - Should supress corticol secretion - In some mood disorders, it does not

  23. Etiology of Mood DisordersSocial Factors • Stressful life events • 42-67% of depression occurs within a year of a major stressful life event • Long-term chronic stressors • e.g. poverty • Vulnerability to stress • Lack of social support • Support minimises the effect of social stressors • E.g. 40% prevalence in women without confidants, 4% in women with confidants • Interpersonal relations • Depressive symptoms elicit negative reactions • Excessive reassurance seeking results in rejection

  24. Nutritional Treatment • Potential therapeutic benefit of n-3 polyunsaturated fatty acids (Omega 3) • Vitamin B12, B3- necessary for the synthesis of red blood cells, the maintenance of the nervous system and growth and development in children • deficiency of this particular vitamin results in an build up of a compound called homocysteine- this may enhance depression.

  25. Stage 2: 6 months – 2 years • Visual acuity allows the child to focus on outside objects and gain a wider visual perspective • Awareness grows of objects outside of immediate range • “Hatching” (Mahler) – moving away from mother in brief episodes of independence • Begins to separate self from other eliciting • Fear and excitement • Diversity and choice

  26. Obsessive-Compulsive Disorder (OCD) • 2% prevalence, common onset around age 10 • Obsessions: • Intrusive and recurring thoughts, images or impulses that are uncontrollable and come unbidden • e.g. contamination, safety, religious issues • Compulsions: • Repetitive, clearly excessive behaviours or mental acts to reduce anxiety caused by obsessive thoughts. • e.g. elaborate rituals of orderliness, repetitive, magically protective acts (superstitions) • Repeatedly checking that these acts are carried out •  lack of confidence in memory, unduly concerned about gaps in memory

  27. Stage 2: Separation and Connection • Separation from the mother corresponds with separation of self from other • Separation from primary attachment figure leads to binary distinctions • Duality: • good-bad, • pleasure-pain, • closeness-distance, • self-other

  28. 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

  29. 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)

  30. 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

  31. 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

  32. 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

  33. 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

  34. Attention Deficit/Hyperactivity Disorder 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

  35. Etiology of ADHD • 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

  36. Conduct Disorder(Including Oppositional Defiant Disorder) • 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

  37. Antisocial Personality Disorder and Psychopathy • Antisocial personality Disorder: • A pervasive pattern of disregard for the rights of others since the age of 15. • The presence of a conduct disorder before the age of 15. Truancy, running away from home, frequent lying, theft, arson, and deliberate destruction of property • Psychopathy • Poverty of emotions. • No sense of shame • Superficial charm to manipulate others for personal gain • Lack of anxiety may make it impossible to learn from their mistakes

  38. Stage 4: 4 – 7 years Behaviours are consciously adapted to gain or express love Ego development forms the foundation for relationship with others Family provide the first model for relationship formation Internalised family relationships are used for interaction with peers Self-esteem is greatly influenced by these relationships

  39. Stage 4: Social Identity • Social identity (“Persona” – mask) created to interact with others • The part of ourselves that the ego allows to rise above the surface, subsequent to consequence (response) control • Self-concept initially based on how we are treated • Whether we are admired or criticised, identification of self through relationships • Maturation includes perception of service to others • Self-acceptance expands beyond self-centred needs and embraces external awareness

  40. Bowlby’s Attachment Theory • John Bowlby (1969): Attachment Theory • Early emotional communication between children and their significant attachment figures • Directly impacts mental health in later life

  41. Ainsworth’s Strange Situation • Ainsworth (1973) : Strange Situation Paradigm • Assesses security of infant-adult attachment by exposing infants to increasing amounts of stress to observe their organisation of attachment behaviours • Secure • Insecure-avoidant • Anxious-ambivalent • Disorganised (Main & Solomon, 1990) • Predictive of behaviour and mental health in later life

  42. Love • Harlow (1958) • Experimental Monkey mothers – groups with surrogates made from cloth or wire, and presented with fearful or stimulating objects • Basic need in infant monkeys for close contact with something soft and comforting • Babies seek out their mothers when afraid • Attachment persists after periods of seperation

  43. Sexual disorders • mental illnesses involving apparent violations of social norms of sexuality • orientation to include objects, concepts, or in some cases, elements • Paraphilias: eight major categories and seven subtypes • include attraction to unusual objects or activities, sometimes involving sexually deviant behaviours involving harm • Voyeurism, for example, which involves the intense and recurrent desire for sexual gratification through watching others undress or have sex • Sadist needs to inflict physical suffering or humiliation in order to achieve sexual gratification • only diagnosed if present without another axis-I disorder • observation, participation or fantasy must be necessary for the individual to achieve sexual arousal and gratification • a diagnosis under the DSM-IV must be inclusive of subjective distress or impairments in normal functioning

  44. Childhood Sexual Abuse • 13.5% of women, 2.5% of men • About half of children exposed to CSA will develop symptoms such as depression, low self-esteem, conduct disorder or anxiety disorders like PTSD. • Almost half do not appear to experience adverse short-term effects

  45. Pedophilia • Orientations are directed towards children under 13 years of age • Children deemed too young to understand the requirements for informed consent • What is sex, possibilities of psychological and social dilemmas • Any pedophile who does act on their fantasies then becomes a child molester and, if legally convicted of this crime, a sex offender • Studies of pedophiles show less than 15% of them to be classifiable as having a psychopathology under the Minnesota Multiphasic Personality Inventory (Erickson, Luxenberg, Walbek & Seely, 1987). • Only a very small number of pedophiles are actually child molesters, and many child molesters are not, in fact, pedophiles (Diamont & McAnulty, 1995). • Inaccurate beliefs, such as a pedophile thinking that a child can consent to and enjoy sex, may be a vital point for therapeutic modulation

  46. Stage 5: Social Contract • Child identifies self as a role – teacher, mother, artist, businessman • Child also identifies with failures and mistakes • Self is identified with social inspiration – role models • Acts of artists, poets, heroes, mythology, great creations of civilisations etc • Creativity

  47. Personality Disorders • An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the culture of the individual who exhibits it. - APA DSM

  48. Personality Disorders • Odd/Eccentric Cluster • Paranoid Personality Disorder • Schizoid Personality Disorder • Dramatic/Erratic Cluster • Borderline Personality Disorder • Histronic Personality Disorder • Antisocial Personality Disorder and Psychopathy • Narcissistic Personality Disorder • Anxious/Fearful Cluster • Avoidant Personality Disorder • Dependent Personality Disorder • Obsessive-Compulsive Personality Disorder