Chapter 15 Classification issues Childhood Diagnoses AD HD Anxiety Disorders OCD and PTSD Statistical deviation and distress abnormal Classification Issues The parameters of deviance and just being a kid or adult The PI Approach 1 Presence quality and quantity of symptoms 2 Persistence 3 Pervasiveness 4 Impairment 2x 9 symptoms 6 needed for diagnosis in kids lasting 6 months or longer before age 12 Benefits of classification systems Efficiency of communication Guiding of research Prediction Guiding of 3rd party reimbursement Guiding of assessment and treatment Cons dangers of classification systems Loss of information categorical model of classification you have the condition or your don t Limit attention resources directed toward at risk youth Labeling effects Artificial dichotomy Over diagnosis false positives Focus is on putting out fires not preventing them History of the DSM 5 May 2013 Historical treatment of child disorders Discrete diagnostic categories categorical medical Increasing emphasis on research psychoanalytic lens disappeared Research symptoms driving content not traits from 1980 1952 DSMI 1968 DSM II 1980 DSM III 1987 DSM III R Revised 1994 DSM IV 2000 DSM IV TR Text Revision 2013 DSM 5 Pre 1980 Editions did not focus on child disorders Dominant lens was psychoanalysis Adultomorphism Kids viewed as Emergent adults 1980 onwards Atheoretical and polythetic approach o Lens neutral behavior focused no cause definitions Explicit behavioral criteria reliability and validity increases Call for diagnostic calm 20 year gap in diagnosis ensued 3 out of 15 symptoms needed for conduct disorder DSM5 May 2013 Highlight of changes New diagnosis and names Revised symptoms and cut scores o ADHD originally based on kids modified for adults e g excoriation disorder finger picking Reordering and reassigning Enhanced specifiers severity ratings Change from Roman numerals to Arabic numerals Childhood Diagnosis AD HD Russell Barkley is an expert on AD HD George Still and the Royal Academy of Physicians 1902 20 child case studies pattern of impaired volitional controlled inhibition 3 1 male to female ratio family history of similar impulsivity alcoholism criminality and depression suggested neurological impairment aggressive passionate lawless inattentive impulsive overactive defect in moral control Encephalitis swelling of brain tissue epidemics of 1917 1918 resulted in Still s symptoms AD HD defined by cause or cause symptoms Minimal brain damage and minimal brain dysfunction 1950s 1960 s DSMII 1968 and focus on hyperactivity hyperkinetic reaction of childhood or adolescence DSM III 1980 and focus on inattention ADD with hyperactivity ADD without hyperactivity DSM III R 1987 and attention deficit hyperactivity disorder ADD without hyperactivity undifferentiated ADD DSM IV and DSM 5 Same name two symptom lists three subtypes o Predominantly inattentive o Predominantly hyperactive impulsive o Combined o Over diagnosis and importance of careful and comprehensive assessment Specific Change in DSMs Placement in Neurodevelopmental disorders Examples added to symptoms list Age of onset changed from 7 12 Pervasiveness criticism strengthened several symptoms in multiple settings needed Symptom threshold lowered for adults 5 out of 9 needed PI criteria revisited Presence two 9 item symptom lists o 6 need on one or both for child diagnosis o 3 presentations needed in different settings persistence 6 months before age of 12 pervasiveness 2 settings impairment AD HD Prevalence epidemiology and Correlates What diagnosis go with AD HD approximately 3 7 of school age children suffer from clinically significant levels of AD HD symptoms 2 1 9 1 male to female ratio Common Comorbidities likeliness for combined disorders rule rather than exception o Oppositional deficit and conduct disorder 75 of combined kids o Anxiety and or Depression 25 of combined kids o Learning disorders 25 of combined kids AD HD Etiology cost Heritability estimates 64 91 with putative mechanisms of the dopamine transporter gene birth complications maternal substance use the frontal lobes family conflict and overall goodness of fit between child and environment executive functions various goal directed processes involved in selecting inhibiting and organizing thought and behavior two people with AD HD cant have the same cause equifinality principle for which you interpret all diagnosis o multiple causes of equal outcome The Prefrontal Striatal Region limbic system striatum morphometric analysis nerves bundles travel from frontal prelobes nerves bundles stronger in people with AD HD sensitivity concerns not every kid with AD HD has frontal lobe issues Specificity concerns kids and adults with other diagnosis also have other frontal lobe issues Frontal lobe is not entirely accurate Anxiety Disorders OCD and PTSD Anxiety Anticipation that negative events are forthcoming Varies in scope one thing or generalized and symptom presentation Inappropriate excessive and or unreasonable General Signs and Symptoms and catastrophizing Cognitive anticipation that negative events are forthcoming e g what ifs o Maximum potential for negatives minimal potential for positives Behavioral avoidance of feared situations perfectionism and o Most common compulsions counting checking cleaning Physiological palpitations sweating trembling dizziness and shortness compulsions of breath Disorders 10 of people cross diagnosis thresholds for a disorder Select diagnosis focus and nature of fear o Specific Phobia p615 fear focused on specific object situation o Social Anxiety Disorder p615 embarrassment lack of performance negative evaluation o Panic disorder 614 sudden surge of physical disorder o Generalized anxiety disorder p614 worries about everything can respond to therapy o OCD p 616 DSM5 O C and related DOs Recurrent distressing thoughts that you know are irrational e g contamination or fear of hurting Not a disorder now Repeated behavior similar to hoarding You know its not normal Schitz think you re right o PTSD p616 DSM 5 trauma and stressor related DOs Have trauma Talk through don t avoid Exposure therapy Anxiety Prevalence p 645 Cormorbidities relates to another anxiety disorder o Depression usually preceded by anxiety Correlates o Temperamental over reactivity 1 3 of kids studied cross diagnosis thresholds o Additional bias for threat stimuli o Sequential cormorbidity Overly restrictive and controlling parenting Family history of anxiety
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