Disorders First Diagnosed

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Disorders First Diagnosed

  1. 1. Week 7 COS Disorders First Diagnosed in Infancy
  2. 2. Agenda for Today <ul><li>Homework review </li></ul><ul><li>COS – Article review </li></ul><ul><li>An Introduction to Disorders First Diagnosed in Infancy </li></ul><ul><li>Article reviews </li></ul>
  3. 3. Childhood Onset Schizophrenia (COS)
  4. 4. Childhood Onset Schizophrenia (COS) <ul><li>Historically, autism and other PDD’s were associated with schizophrenia </li></ul><ul><li>In comparison to autism- later age of onset , less intellectual impairment, less severe social and language deficits, hallucinations and delusions , periods of remission and relapse </li></ul><ul><li>COS is not distinct from adult schizophrenia, rather, it is a more severe form </li></ul>
  5. 5. DSM-IV Features of COS <ul><li>Hallucinations- often auditory </li></ul><ul><li>Delusions </li></ul><ul><li>Disorganized speech </li></ul><ul><li>Disorganized or catatonic behavior </li></ul><ul><li>“ Negative” symptoms (e.g., flat affect, alogia, avolition) </li></ul>
  6. 6. Prevalence and Course <ul><li>Extremely rare in children under age 12 (.14 - 1 per 10,000 children) </li></ul><ul><li>COS twice as common in boys (gender differences disappear in adolescence) </li></ul><ul><li>Gradual onset- 90% show a clear history of behavioral and psychiatric disturbances prior to onset of psychosis </li></ul><ul><li>High comorbidity with conduct problems and depression </li></ul>
  7. 7. Causes of COS <ul><li>Current views emphasize a vulnerability-stress model </li></ul><ul><li>Preliminary evidence suggest a strong genetic contribution in COS, even more so than for adults </li></ul><ul><li>COS appears to be particularly associated with family stress </li></ul>
  8. 8. Treatment of COS <ul><li>COS is a chronic disorder with a poor long-term prognosis </li></ul><ul><li>Pharmacological treatments, particularly neuroleptics, may be used to help control psychotic symptoms </li></ul><ul><li>Psychosocial treatments, such as social skills training, family intervention, and special school placement, are also important </li></ul>
  9. 9. An Introduction to Disorders First Diagnosed in Infancy
  10. 10. Housekeeping <ul><li>Zeanah et al. (1997). Relationship Assessment in Infant Mental health.(Posted) </li></ul><ul><li>Additional reading : </li></ul><ul><li>Selma Fraiberg : Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. </li></ul>
  11. 11. Disorders First Diagnosed in Infancy
  12. 12. Disorders First Diagnosed in Infancy <ul><li>What is Infant Mental Health? </li></ul>
  13. 13. What it is NOT…
  14. 14. Infant Mental Health <ul><li>What are some problems for which Infants get referred to mental health services ? </li></ul><ul><li>Who refers infants to mental health services? </li></ul>
  15. 15. Disorders First Diagnosed in Infancy <ul><li>What criteria do we use? </li></ul>
  16. 16. Zero to Three Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood <ul><li>To address need for a systematic, developmentally-based approach to classification of mental health difficulties in first 4 years of life </li></ul><ul><li>To complement, not replace, existing frameworks </li></ul>
  17. 17. Zero to Three Diagnostic Classification <ul><li>Axis I: Primary Classification </li></ul><ul><li>Axis II: Relationship Classification </li></ul><ul><li>Axis III: Physical, Neurological, Developmental, Mental health Disorders or Conditions (described in other systems) </li></ul><ul><li>Axis IV: Psychosocial stress </li></ul><ul><li>Axis V: Functional Emotional Developmental Level </li></ul>
  18. 18. Zero to Three Diagnostic Classification - Axis I: Primary Diagnosis <ul><li>Traumatic stress disorder </li></ul><ul><li>Disorders of affect </li></ul><ul><li>Anxiety Disorders of Infancy & Early Childhood </li></ul><ul><li>Mood Disorder: prolonged grief reaction </li></ul><ul><li>Mood Disorder: Depression of Infancy & Early Childhood </li></ul>
  19. 19. Zero to Three Diagnostic Classification - Axis I: Primary Diagnosis <ul><li>Mixed Disorder of Emotional Expressiveness </li></ul><ul><li>Childhood Gender Identity Disorder </li></ul><ul><li>Reactive Attachment Deprivation / Maltreatment Disorder of of Infancy & EC </li></ul><ul><li>Adjustment Disorder </li></ul><ul><li>Regulatory Disorders: Type I, II, III, IV </li></ul>
  20. 20. Zero to Three Diagnostic Classification - Axis I: Primary Diagnosis <ul><li>Sleep Behaviour Disorder </li></ul><ul><li>Eating Behaviour Disorder </li></ul><ul><li>Disorders of Relating & Communicating: Multisystem Developmental Disorder and PDD: Pattern A, B, C </li></ul>
  21. 21. Zero to Three Diagnostic Classification - Axis II: Relationship Disorder classification <ul><li>Overinvolved </li></ul><ul><li>Underinvolved </li></ul><ul><li>Anxious / Tense </li></ul><ul><li>Angry / Hostile </li></ul><ul><li>Mixed </li></ul><ul><li>Abusive: verbally, physically, sexually </li></ul>
  22. 22. Focus in infant mental health practice <ul><li>Infant self regulation </li></ul><ul><li>Quality of parent-infant relationship </li></ul><ul><li>Attachment </li></ul>
  23. 23. Infant Mental Health <ul><li>What are our beliefs, is our focus in Infant Mental Health? </li></ul><ul><li>Infant – Caregiver relationship is the crucial context for infant development </li></ul><ul><li>Patterns of relating are transmitted from generation to generation </li></ul><ul><li>These patterns are stable and predictive </li></ul><ul><li>Non-shared environmental influences are critical </li></ul><ul><li>From Zeanah (1997) </li></ul>
  24. 24. The parent – infant dyad <ul><li>CHILD </li></ul><ul><li>Physical challenges </li></ul><ul><li>Neurobiology </li></ul><ul><li>Temperament </li></ul><ul><li>Regulation </li></ul><ul><li>Cognition </li></ul><ul><li>Environment </li></ul><ul><li>CAREGIVER </li></ul><ul><li>Physical challenges </li></ul><ul><li>Neurobiology </li></ul><ul><li>Temperament </li></ul><ul><li>Regulation </li></ul><ul><li>Cognition </li></ul><ul><li>Environment </li></ul><ul><li>History </li></ul><ul><li>Communication </li></ul><ul><li>Interaction </li></ul><ul><li>Cognition </li></ul>
  25. 25. Regulation <ul><li>Biological </li></ul><ul><li>Emotion </li></ul>
  26. 26. Emotion Regulation vs Reactivity <ul><li>emotional reactivity: tendency to react to positive or negative events (Kunzmann & Grühn, 2005) </li></ul><ul><li>emotion regulation: processes by which individuals (consciously or unconsciously) influence the experience and expression of emotions (Gross, 1998). </li></ul>
  27. 27. Emotion Regulation vs Reactivity <ul><li>Emotional reactivity: assessed using frustration tasks designed to elicit distress </li></ul><ul><li>Emotional regulation: assessed by examining the child's behaviors (venting, distraction, focal-object focus, self-orientation, and mother-orientation) when confronted by distress-eliciting tasks. </li></ul>Eisenberg & Fabes, 1997; Calkins et al., 1999
  28. 28. Regulatory Disorders Distinct Behavioral Pattern Processing Difficulty Sensory Sensorimotor Organizational PLUS Affects daily adaptation, interaction or relationships
  29. 34. Regulatory Disorders I II III IV Hypersensitive Under-reactive Motorically Disorganized Impulsive Other Fearful and cautious Withdrawn and difficult to engage Behavioral pattern Negative and defiant Self-absorbed motor and sensory patterns
  30. 35. Regulatory Disorders- Differential Diagnosis of Excessive Crying Medical Illness Infant 6 weeks to 6 months old Colic Gastroesophageal Reflux <ul><li>Onset at 6 weeks. Lasts up to six months. Starts in evening </li></ul><ul><li>Gas in abdomen. Arch legs </li></ul>Regulatory disorders Long-term effects of street drugs Parenting Problems Allergy to milk Rarely is the cause
  31. 36. What do you think <ul><li>Case study </li></ul>
  32. 37. The parent – infant dyad Stern-Brushweiler & Stern (1989) model
  33. 38. The parent – infant dyad Domains of Infant-Caregiver relationship <ul><li>Infant domains </li></ul><ul><li>Vigilance/self-protection </li></ul><ul><li>Emotion regulation </li></ul><ul><li>Security/self-esteem </li></ul><ul><li>Learning/curiosity/mastery </li></ul><ul><li>Play/imagination </li></ul><ul><li>Self-control/cooperation </li></ul><ul><li>Self-regulation/structure </li></ul><ul><li>Parent Domain </li></ul><ul><li>Protection </li></ul><ul><li>Emotional availability </li></ul><ul><li>Nurturance/valuing/ </li></ul><ul><li>empathic responsiveness </li></ul><ul><li>Teaching </li></ul><ul><li>Play </li></ul><ul><li>Discipline/limit setting </li></ul><ul><li>Instrumental care/ routine </li></ul>Zeanah (1997) ;Adapted from Emde (1989)
  34. 39. Attachment & Attachment Disorders
  35. 40. Attachment Disorders <ul><li>Attachment: What is it? </li></ul><ul><li>Infant’s protector: attachment figure </li></ul><ul><li>Bowlby (1969):Infant’s confidence in the capacity of the protector to provide protection </li></ul><ul><li>“ Attachment system” is activated when safety is threatened </li></ul><ul><ul><ul><ul><li>Emotional upset </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physical hurt </li></ul></ul></ul></ul><ul><ul><ul><ul><li>illness </li></ul></ul></ul></ul>
  36. 41. Attachment Patterns <ul><li>Normal - “Organized’ Attachment Pattern (Ainsworth, 1978) – Strange Situation </li></ul><ul><li>Secure </li></ul><ul><li>Insecure Avoidant : rejecting parents </li></ul><ul><li>Insecure-Ambivalent / Resistant : inconsistent parent </li></ul>
  37. 42. Attachment Patterns <ul><li>“ Disorganized ” Attachment Pattern ( Main & Solomon, 1986) </li></ul><ul><li>Attachment disorganization: frightening / frightened parent </li></ul><ul><li>Poor prognosis for child </li></ul>
  38. 43. Attachment Disorders VS Attachment Patterns <ul><li>Bowlby (1973): connections between insecure attachment patterns & particular psychopathologies </li></ul><ul><li>Now: we look not just for insecure patterns, but also watch for organized VS disorganized patterns </li></ul><ul><li>Disorganized: Most at risk (Carlson, 1998; van IJzendoorn, Schuengel & Bakermans-Kranenberg, 1999). </li></ul>
  39. 44. Attachment Disorders VS Attachment Patterns <ul><li>Reactive Attachment Disorder </li></ul>
  40. 45. <ul><ul><li>DSM IV-TR Diagnostic criteria Reactive Attachment Disorder of Infancy or Early Childhood </li></ul></ul><ul><li>Children with this mental disorder , associated with care that is &quot;grossly pathological,&quot; fail to relate socially either by exhibiting markedly inhibited behavior or by indiscriminate social behavior. </li></ul><ul><li>A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2): (1) persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness) </li></ul>
  41. 46. (2) diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) B. The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation ) and does not meet criteria for a Pervasive Developmental Disorder . C. Pathogenic care as evidenced by at least one of the following: (1) persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection (2) persistent disregard of the child's basic physical needs (3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)
  42. 47. <ul><li>D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C). </li></ul><ul><li>Specify type: </li></ul><ul><ul><li>Inhibited Type: if Criterion A1 predominates in the clinical presentation Disinhibited Type: if Criterion A2 predominates in the clinical presentation </li></ul></ul>
  43. 48. Attachment Disorganization
  44. 49. Attachment Disorganization <ul><li>Two components: </li></ul><ul><ul><li>Child’s behaviour </li></ul></ul><ul><ul><li>Caregiver behaviour </li></ul></ul>
  45. 50. Attachment Disorganization <ul><li>Solomon’s (1999) criteria for diagnosis of Attachment Disorganization – Child behaviours </li></ul><ul><li>Sequential display of contradictory behaviours </li></ul><ul><li>Simultaneous display of contradictory behaviours </li></ul><ul><li>Undirected, misdirected, incomplete, interrupted movements and expressions </li></ul><ul><li>Stereotypies, asymmetrical or mistimed movements </li></ul><ul><li>Freezing, stilling, slowed movements </li></ul><ul><li>Direct indices of apprehension re. parent </li></ul><ul><li>Direct indices of disorganization or disorientation </li></ul>
  46. 51. Attachment Disorganization <ul><li>Caregiver atypical behaviours (Lyons-Ruth, 1997; Benoit, 2002) </li></ul><ul><ul><ul><li>Affective communication errors </li></ul></ul></ul><ul><ul><ul><li>Role / boundary confusion </li></ul></ul></ul><ul><ul><ul><li>Fearful behaviour </li></ul></ul></ul><ul><ul><ul><li>Intrusiveness / negativity </li></ul></ul></ul><ul><ul><ul><li>Withdrawal </li></ul></ul></ul>
  47. 52. Test yourself <ul><li>Attachment security VS </li></ul><ul><li>Attachment disorganization VS </li></ul><ul><li>Attachment disorder </li></ul>
  48. 53. What does it look like? <ul><li>Film clips </li></ul>
  49. 54. What do you think? <ul><li>What disturbing behaviours can you note that fit a disorganized pattern? </li></ul>
  50. 56. Article reviews

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