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Terms in this set (170)

Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
Often fidgets with or taps hands or feet or squirms in seat.
Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
Often unable to play or engage in leisure activities quietly.
Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
Often talks excessively.
Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation).
Often has difficulty waiting his or her turn (e.g., while waiting in line).
Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
A. Persistent difficulties in the social use of verbal & nonverbal communication [with] all of:
1. Deficits in using communication for social purposes
2. Impairment of the ability to change communication to match context or the needs of the listener
3. Difficulties following rules for conversation and storytelling
4. Difficulties understanding what is not explicitly stated
B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in any combination.
C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities).
D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by ASD, intellectual disability (IDD), global developmental delay, or another mental disorder.
Symptoms: Sparse language, terse responses, problems initiating and maintaining conversations, inappropriate turn taking, irrelevant comments, deficient conversational repair skills, deficient narrative skills, Pragmatic difficulties dissociated from phonological and semantic-syntactic problems, Pragmatic problems in both production and comprehension, socially inappropriate and does not meet full criteria for ASD
Comorbid:
with ADHD, behavioral problems, and Specific Learning Disorder
Course:
Can typically be diagnosed by age 5
Milder forms may not become apparent until later
Outcome is variable
Some improve substantially
Other have difficulties persisting into adulthood
Risk Factors:
Early pragmatic deficits can cause lasting impairments in social relationships and behavior, and acquisition of related skills
Treatment:
For those with trouble (avoidance) initiating a conversation, therapist might:
1. Give instructions on the importance of eye contact
-Model appropriate eye contact
-Prompt its use
-Reinforce attempts
2. Prompt conversation-starting
-Place pictures in the office that require the child to ask questions
-Provide a story stem
-Reinforce
3. Maintain conversation
-"Tell me more"
-Encourage children to stay on topic
-Teach turn-taking skills
A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties:
(Reading)
1. Inaccurate and slow and effortful word reading
2. Difficulty understanding the meaning of what is read
(Written Expression)
3. Difficulties with spelling
4. Difficulties with written expression
(Mathematics)
5. Difficulties mastering number sense, number facts, or calculation
6. Difficulties with mathematical reasoning
B. The affected academic skills are substantially and quantifiably below those expected for the individual's chronological age, and cause significant interference with academic or occupational performance, or with activities of daily living, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment. For individuals age 17 and older, a documented history of impairing learning difficulties may be substituted for the standardized assessment.
C. The learning difficulties begin during school-age years but may not become fully manifest until the demands for those affected academic skills exceed the individual's limited capacities (e.g., in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively heavy academic loads).
D. The learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction.
-The difficulty may be restricted to one academic skill or domain
-Not due to intellectual disability, hearing or vision disorder, or other neurological disorders
-Affects learning in individuals who otherwise show normal levels of intellectual functioning (IQ is not significantly low)
-Cannot be attributed to economic or environmental disadvantage, chronic absenteeism, or lack of education
A. Difficulties might be in any combination of the following:
Word recognition
1. Pronunciation
2. Vocabulary
3. Reading fluency
4. Comprehension
5. Memory for read material
B. Visual-perceptual deficits?
-Not supported by evidence; often, words can be copied correctly and still not identified properly
-Explicitly outside of the definition of specific learning disorder
C. Phonological processing deficits
1. Deficits in phonological awareness understanding the basic sounds of language
2. Deficits in phonological encoding - mapping graphemes to phonemes
3. Improving phonological processing improves reading
4. Not the whole story
1. Some kids with no deficiency have difficulties in understanding what they read
2. Specific Learning Disorder in Reading may be heterogeneous, with different kids showing deficits in different subprocesses
Prevalence & Course:
- ~5% of US school age population
-More boys than girls
-Reading problems tend to persist, but may improve with early intervention
-Ability to attend affects prognosis/course
The language being learned makes a difference
-The more phonetic the spelling, the fewer reading problems tend to occur
-Problems may instead be seen in fluency (good indicator of Specific Learning Disorder in reading in adults)
-Differences in logographic languages - more influence of visual processing, more activation of RH
Risk and resiliency factors:
1. Mother's reading ability- good = good for child
2. Initial severity of reading problems
3. Instruction
4. Ability to attend
5. Reading models
6. Worse prognosis with comorbid ADHD
-Many different mathematical skills may be problematic
--Reading numbers
--Performing simple addition and subtraction
--Understanding arithmetic terms and symbols
--Memorizing mathematical facts
--Understanding spatial organization
-Counting skills develop by age 5
-More sophisticated and short-cut strategies to mathematical problems develop later
--Counting all becomes counting on, becomes stored knowledge
--Example: Add 4 + 2
--Count all: 1, 2, 3, 4, 5, 6
--Count on: 4, 5, 6
--Stored knowledge: 4 +2 = 6
--More advanced strategies free up working memory, allowing children to perform more complex calculations in their heads
EXAMPLE:
First graders with Specific Learning Disorder - Mathematics exhibit problems with:
1. Number
-May still not know number names ("8" or "eight")
-May not know which number is larger or smaller
2. Counting
-Don't understand or consistently implement one-to-one correspondence between number label and object
-Don't understand or consistently implement stable order of number terms across sets of objects
-Don't understand cardinality; when you finish counting, you have enumerated the entire set.
-Delay in understanding flexibility in counting (e.g. may count right to left instead of left to right)
3. Slower to acquire more advanced strategies
4. Employ advanced strategies less frequently, less quickly, and less accurately
5. Deficits may also be seen in underlying cognitive processes, such as working memory, executive functions, and visuospatial skills
--May have difficulty retaining mathematical facts or may forget these facts quickly
Prevalence & Course:
~0.5-1% school-aged children
Prevalence may be even lower for pure cases without comorbid Specific Learning Disorder - Reading or ADHD
Mixed cases are associated with the worst outcomes
Boys = girls
Though boys may be more likely to receive services because of disruptive behavior (referral bias?)
Comorbidities
Specific Learning Disorder - Reading
ADHD
Behavioral disturbances
Likely to be persistent, especially without intervention, and especially when comorbid with ADHD
Characteristics:
1. Intellectual Functioning:
Score lower on standardized tests
Lower grades
Poor concentration
Psychomotor retardation
Fatigue
Insomnia
Somatic complaints
2. Cognitive Disturbances:
Feelings of worthlessness
Negative beliefs
Attributions of failure
Depressive ruminative style
Focus narrowly on negative events for long periods
3. Social Problems:
Social withdrawal
4. Family Problems:
Poor relations and conflict with parents and siblings
Symptoms:
1. Mood
-Sadness more exaggerated and persistent
Irritability, guilt, shame
2. Behavior
-Restlessness, agitation, reduced activity, slowed speech, excessive crying
3. Changes in attitude
-Feelings of worthlessness and low self-esteem
4. Thinking
-Preoccupied with inner thoughts and tensions
-Slowed thought, distorted reasoning, difficultly concentrating
5. Physical changes
-Disruptions in eating and sleeping
Developmental Stages:
1. Preschoolers
Extremely somber and tearful
Clingy, fear separation
Stomachaches
Disruptions in eating may be lack of typical weight gain
2. School aged children
Irritability, disruptive behavior, temper tantrums
Weight loss, headaches, sleep disturbances
Suicide threats
3. Preteens
Self-blame, low self-esteem, social inhibition, hopelessness
Sleeping difficulties
4. Teens
Inability to sleep or sleep excessively
Eating disturbances
Irritability
Anhedonia
Angry discussions with parents
Negative body image and self-consciousness
Excessive fatigue and energy loss, feelings of loneliness, guilt, worthlessness
Suicidal thoughts and attempts
Theories:
1. Psychodynamic
Caused by a loss of or separation from love objects
Superego punishes the ego
Anger turned inward
2. Temperament
Difficult temperament increases child's negative emotions
Overreaction to life events, difficulty regulating emotions
May elicit negative reactions from caregivers and peers
3. Attachment
Insecure early attachments
Derive self-esteem from accomplishments and approval of others
Need attention and reassurance to maintain sense of worthiness
Underutilize social support networks in times of crisis
4. Behavioral
Positive reinforcement
5. Cognitive
Separation as learned helplessness
Internal, stable and global attributions for unfortunate events
External, unstable, and specific for positive life events
Negative view of self, world and future:
Catastrophizing, overgeneralization, dichotomous thinking, mind, personalization, absolute thinking
Key features:
Sadness
Irritability
Anhedonia
A. 5 (or more) symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gain.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
D. The occurrence of the major depressive episode is not better explained by Schizophrenia or a psychotic disorder.
e. There has never been a manic or hypomanic episode.
Specify course:
Single episode: Only one major depressive episode
Recurrent: Two or more major depressive episodes, with at least two months between episodes in which the individual does not meet criteria.
Specify current severity:
1. Mild: Few, if any, symptoms in excess of those required to make the diagnoses are present, the intensity of the symptoms is manageable, and the symptoms result in minor impairment.
2. Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for "mild" and "severe."
3. Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with functioning.
Prevalence:
Preschoolers: 1%
School aged: 2%
Adolescents: 8%
Lifetime prevalence: 20%
Under 13: girls = boys
Over 13: girls > boys
-Excessive empathy, excessive compliance, -problems with emotion regulation
-Hormonal changes
-Increasing sexual maturity may affect social roles

Comorbidities:
(particularly for those with recurrent MDEs)
-Separation Anxiety Disorder
-Substance Use Disorders
-Panic Disorder
-OCD
-Anorexia Nervosa
-Bulimia Nervosa
Chart:
Euthymic-Depressed-Euthymic
Display depressed mood for most of the day, on most days, for at least 1 year (in children and adolescents)
Unhappy or irritable most of the time
Usually begins gradually, whereas MDD onset is rapid
Symptoms chronic, but less severe than those with MDD
Symptoms:
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. Over the last 2 years there is at least one period of two months or longer during which the full criteria for a Major Depressive Episode are not met (i.e., the current episode is not better accounted for by Chronic MDD Note: Dysthymic Disorder may precede or follow a chronic major depression.
E. There has never been a Manic Episode or a Hypomanic episode and criteria for current Cyclothymic Disorder are not met.
F. The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as Schizophrenia or Delusional Disorder.
G. The symptoms are not better accounted for by the direct physiological medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social occupational, or other important areas of functioning.
Specify:
1. With pure dysthymic syndrome: Full criteria for a major depressive episode have not been met in the preceding two years.
With persistent major depressive episode: Full criteria for a major depressive episode have been met through the preceding 2-year period.
2. With intermittent major depressive episodes, with current episode: Full criteria for a major depressive episode are currently met, but there have been periods in the preceding 2 years with symptoms below threshold for a full major depressive episode.
3. With intermittent major depressive episodes, without current episode: Full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in the preceding 2 years.
Prevalence:
Children: 1%
Adolescents: 5%
During the course of Persistent Depressive Disorder, ~70% may have an episode of Major Depression (double depression)
Comorbidities:
MDD
Social Anxiety Disorder
Other anxiety disorders
Substance Use Disorders
Course:
Persistent depressive disorder develops about 3 years earlier than MDD
Typical age of onset is about 11-12 years of age
Duration: 2-5 years
Chart:
Euthymic-steady BTW Euthymic and Depression
A. Criteria have been met for at least one manic episode
(see next slide)
B. The occurrence of the manic episode is not better explained by Schizophrenia or another psychotic disorder.
Manic Episode:
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree, and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
-The episode is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or to another medical condition.
Manic Symptoms:
Frequency, Intensity, Number, Duration (FIND)

Elated Mood
"Normal": Very excited to go to Disneyland
Mania: 7 year old repeatedly taken to the principal for giggling when no one else was
Grandiose Behaviors
"Normal": 7 year old pretended to be a fireman rescuing victims. He did not call the firehouse.
Mania: 7 year old boy stole a go-cart. He knew it was wrong to steal, but did not believe it was wrong for him. He thought that the police were arriving to play with him.
Differences between Adults and Children:
Adults
Distinct periods of mania and/or depression
Good functioning in between
Mania, defining characteristic
Kids and adolescents
Short episodes
Frequent mood shifts
Mixed moods
"Chocolate milk"
"Fudge ripple"
Irritability most common manifestation of bipolar disorder in children
Prevalence & Comorbidities:
Lifetime prevalence 1.8%
For I and II combined
Girls = boys
Comorbidities:
Anxiety disorders
In about 75%
During depressive states
ADHD
ODD & Conduct Disorder
Substance Use Disorders
During manic states
Eating disorders
Particularly BED
During depressive states
Course:
20% of all patients with BD have their first episode in late adolescence
-Onset before 10 is rare
-Childhood or adolescent onset is associated with a more severe course and worse prognosis
Youths with BDs typically recover from their initial episode, however, relapse is likely; often chronic
-In 5 years, 60% relapsed or never fully recovered
Youths with BDs experience discrete mood episodes, usually long periods of depression. Between episodes, they typically show subthreshold symptoms of depression
-Youths with BDs often show mixed mood symptoms (e.g., excitability, agitation, irritability, and sadness)
-Median duration of manic episodes is 10.8 months
-Estimated mean duration of the mood disturbance is 80.2 months compared to 15.7 months for MDD
Causes:
1. Strong genetic component
-Risk is 5-10x greater when a parent has BD
2. Reduced brain volume
3. Hyperactivation of the amygdala, hypoactivation of prefrontal cortex
-Seeing more threats
3. Lower frustration tolerance
4. Perpetuating: high expressed parental emotion
-Critical
"Why can't you be responsible like other kids your age and remember to do your homework?"
-Hostile
"You make me sick."
-Over-involved
"I lie awake at night worrying about you. Are you safe?"
Treatment:
Antipsychotics,(Chlorpromazine) Psychotic symptoms, aggression, severe anxiety, Bipolar Disorder and Mood Stabilizers, (Lithium or Depakote) Mania, schizoaffective disorder
Atypical antipsychotics are often the first-line treatment now
-Approved in those aged 10-17: Abilify, Seroquel, Risperdal, (Zyprexa for ages 13-17)
-Affect dopamine, serotonin, and norepinephrine
-Bind more weakly to dopamine receptors, causing fewer side effects
- ~50% see reduction in manic symptoms (~25% with placebo)
- Response rates ~2x as high as to lithium
Mood stabilizers: Lithium
- Low effectiveness, high drop-out rate, high side effects
Antidepressants may create mania
Psychotherapy may increase compliance with medication and prevent recurrence of symptoms
-Psychoeducation, improving emotion-regulation and communication
Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
The temper outbursts are inconsistent with developmental level.
The temper outbursts occur, on average, three or more times per week.
The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers).
Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D.
Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these.
The diagnosis should not be made for the first time before age 6 or after age 18.
By history or observation, the age at onset of Criteria A-E is before age 10 years.
There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.
The behaviors do not occur exclusively during an episode of MDD and are not better explained by another mental disorder (e.g., ASD, PTSD, SAD, persistent depressive disorder).
Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including MDD, ADHD, CD, and substance use disorders. Individuals whose symptoms meet criteria for both DMDD and ODD should only be given the diagnosis of DMDD. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of DMDD should not be assigned.
The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.
Based on preliminary research, prevalence of DMDD is ~2-5% of those age 6-18
DMDD in childhood may be a risk factor for depressive disorders and GAD in adulthood
About 2/3 of DMDD cases are in males
DMDD may be highly related to ODD, with the most extreme (~15%) ODD patients instead being diagnosed with DMDD
Impaired face processing, particularly for negative emotions such as "sad", "fearful" and "angry"
Underactivity of the amygdala during face perception
Decreased context-sensitive regulation
Treatment: antidepressants, parent training, CBT, comprehensive family therapy
Antidepressants, parent training, CBT, comprehensive family therapy