disorders first diagnosed

Week 7COSDisorders First Diagnosed in Infancy

Agenda for Today

Homework reviewCOS – Article reviewAn Introduction to Disorders

First Diagnosed in InfancyArticle reviews

Childhood Onset Schizophrenia (COS)

Childhood Onset Schizophrenia (COS)

Historically, autism and other PDD’s were associated with schizophrenia

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

COS is not distinct from adult schizophrenia, rather, it is a more severe form

DSM-IV Features of COS

Hallucinations- often auditoryDelusionsDisorganized speechDisorganized or catatonic behavior“Negative” symptoms (e.g., flat

affect, alogia, avolition)

Prevalence and Course

Extremely rare in children under age 12 (.14 - 1 per 10,000 children)

COS twice as common in boys (gender differences disappear in adolescence)

Gradual onset- 90% show a clear history of behavioral and psychiatric disturbances prior to onset of psychosis

High comorbidity with conduct problems and depression

Causes of COS

Current views emphasize a vulnerability-stress model

Preliminary evidence suggest a strong genetic contribution in COS, even more so than for adults

COS appears to be particularly associated with family stress

Treatment of COS

COS is a chronic disorder with a poor long-term prognosis

Pharmacological treatments, particularly neuroleptics, may be used to help control psychotic symptoms

Psychosocial treatments, such as social skills training, family intervention, and special school placement, are also important

An Introduction to Disorders First Diagnosed in Infancy

Housekeeping

Zeanah et al. (1997). Relationship Assessment in Infant Mental health.(Posted)

Additional reading:Selma Fraiberg : Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships.

Disorders First Diagnosed in Infancy


What is Infant Mental Health?

What it is NOT…

Infant Mental Health

What are some problems for which Infants get referred to mental health services ?

Who refers infants to mental health services?


What criteria do we use?

Zero to Three Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood

To address need for a systematic, developmentally-based approach to classification of mental health difficulties in first 4 years of life

To complement, not replace, existing frameworks

Zero to Three Diagnostic Classification

Axis I: Primary ClassificationAxis II: Relationship ClassificationAxis III: Physical, Neurological,

Developmental, Mental health Disorders or Conditions (described in other systems)

Axis IV: Psychosocial stressAxis V: Functional Emotional

Developmental Level

Zero to Three Diagnostic Classification - Axis I: Primary Diagnosis

Traumatic stress disorderDisorders of affectAnxiety Disorders of Infancy & Early

ChildhoodMood Disorder: prolonged grief

reactionMood Disorder: Depression of Infancy

& Early Childhood


Mixed Disorder of Emotional Expressiveness

Childhood Gender Identity DisorderReactive Attachment Deprivation /

Maltreatment Disorder of of Infancy & ECAdjustment DisorderRegulatory Disorders: Type I, II, III,

IV


Sleep Behaviour DisorderEating Behaviour DisorderDisorders of Relating &

Communicating: Multisystem Developmental Disorder and PDD: Pattern A, B, C

Zero to Three Diagnostic Classification - Axis II: Relationship Disorder classification

OverinvolvedUnderinvolvedAnxious / TenseAngry / HostileMixedAbusive: verbally, physically,

sexually

Focus in infant mental health practice

Infant self regulationQuality of parent-infant relationship Attachment

Infant Mental Health

What are our beliefs, is our focus in Infant Mental Health?

Infant – Caregiver relationship is the crucial context for infant development

Patterns of relating are transmitted from generation to generation

These patterns are stable and predictive Non-shared environmental influences are critical

From Zeanah (1997)

The parent – infant dyad

CHILD

•Physical challenges

•Neurobiology

•Temperament

•Regulation

•Cognition

•Environment

CAREGIVER

•Physical challenges

•Neurobiology

•Temperament

•Regulation

•Cognition

•Environment

•History

•Communication•Interaction•Cognition

Regulation

BiologicalEmotion

Emotion Regulation vs Reactivity

emotional reactivity: tendency to react to positive or negative events (Kunzmann & Grühn, 2005)

emotion regulation: processes by which individuals (consciously or unconsciously) influence the experience and expression of emotions (Gross, 1998).

Emotion Regulation vs Reactivity

Emotional reactivity: assessed using frustration tasks designed to elicit distress

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.

Eisenberg & Fabes, 1997; Calkins et al., 1999

Regulatory Disorders

Distinct BehavioralPattern

Processing DifficultySensorySensorimotorOrganizational

PLUS

Affects daily adaptation, interaction or relationshipsAffects daily adaptation, interaction or relationships

TEMPERAMENT Thomas & Chess, 1963

Biologically - based predisposition to react to environmental events and affective experience DIFFICULT SENSORY REGULATORY TEMPERAMENT MODULATION PROBLEM DISORDER

REGULATORY DISORDER

At least one of (or two of: Sauceda & Garcia 1996):And if they affect daily adaptation and relationships, cause concern in parent &

dysfunction in infant

over or underreactivity to sound, light, visual images, odors, temperature

tactile defensiveness

oral motor difficulties or incoordination / poor muscle tone

oral motor hypersensitivity

motor planning problems

underreactivity to touch or pain

gravitational insecurity

poor muscle tone and muscle stability

deficits in visual spatial processing skills, capacity to attend and focus

EMOTION REGULATION

A Central Concept

Patterns of regulating state and organizing experience develop from repeated interactions between infant and caregiver around achievement of physical, and later emotional homeostasis (Sroufe, 1995)

These same patterns affect development and elaboration of neuronal pathways

activated in early infancy (Schore, 1994) Behaviour of caregiver: central in helping provide infant with state regulation which

is later internalized Also affects regulation of affect, arousal, attention and organization of complex

behaviours e.g. social interaction

REGULATORY DISORDERS VS SENSORY MODULATION DISRUPTIONS

Greenspan & Weider, 1992; Shyu et. al, 1999)

SMD: variations in infant's sensory reactivity

RD: distinct patterns of atypical behaviours coupled with specific difficulties in sensory, sensory-motor ororganizational processing

Difficulty: achieving quiet alert state affectively positive state sustaining attention with routine environmental stimulation

ATYPICAL BEHAVIOURAL PATTERNS = behavioural efforts to accommodate sensory processing difficulties(Greenspan, 1992)

TYPES OF REGULATORY DISORDERS

(Barton & Robins, 2000)

TYPE I : hypersensitive, highly reactive TYPE II: underreactive TYPE III: motorically disorganized / impulsive Subtype: mixed

BUT: sensitivity in one modality may be highly correlated with

sensitivity in other modalities (Miller et al., 2001) No data on temporal stability of regulatory diagnoses Some physiological data Evidence that untreated regulatory disorders persist into pre-school years

(DeGangi, 1991, 1993) Failure to regulate : ADHD /ADD

ODD Tantruming Social Isolation

Regulatory Disorders

I II III IVHypersensitiveUnder-reactiveMotorically

DisorganizedImpulsive

Other

Fearful andcautious

Withdrawn anddifficult to engage

Behavioral pattern

Negative anddefiant

Self-absorbed motor andsensory patterns

Regulatory Disorders- Differential Diagnosis of Excessive Crying

Medical Illness

Infant 6 weeksInfant 6 weeksto 6 months oldto 6 months old

Colic

GastroesophagealReflux

Onset at 6 weeks. Lastsup to six months.Starts in evening

Gas in abdomen. Arch legs

Regulatory disorders

Long-term effectsof street drugsParenting

Problems

Allergy to milkRarely is the cause

What do you think

Case study

The parent – infant dyad

Stern-Brushweiler & Stern (1989) model

The parent – infant dyadDomains of Infant-Caregiver relationship

Infant domains

•Vigilance/self-protection

•Emotion regulation

•Security/self-esteem

•Learning/curiosity/mastery

•Play/imagination

•Self-control/cooperation

•Self-regulation/structure

Parent Domain

•Protection

•Emotional availability

•Nurturance/valuing/

•empathic responsiveness

•Teaching

•Play

•Discipline/limit setting

•Instrumental care/ routine

Zeanah (1997) ;Adapted from Emde (1989)

Attachment & Attachment Disorders

Attachment Disorders

Attachment: What is it?Infant’s protector: attachment figureBowlby (1969):Infant’s confidence in the

capacity of the protector to provide protection

“Attachment system” is activated when safety is threatened

• Emotional upset• Physical hurt• illness

Attachment Patterns

Normal - “Organized’ Attachment Pattern (Ainsworth, 1978) – Strange Situation

SecureInsecure Avoidant : rejecting parentsInsecure-Ambivalent / Resistant :

inconsistent parent

Attachment Patterns

“Disorganized” Attachment Pattern (Main & Solomon, 1986)

Attachment disorganization: frightening / frightened parent

Poor prognosis for child

Attachment Disorders VS Attachment Patterns

Bowlby (1973): connections between insecure attachment patterns & particular psychopathologies

Now: we look not just for insecure patterns, but also watch for organized VS disorganized patterns

Disorganized: Most at risk (Carlson, 1998; van IJzendoorn, Schuengel & Bakermans-Kranenberg, 1999).

Attachment Disorders VS Attachment Patterns

Reactive Attachment Disorder

DSM IV-TR Diagnostic criteria Reactive Attachment Disorder of Infancy or Early Childhood

Children with this mental disorder, associated with care that is "grossly pathological," fail to relate socially either by exhibiting markedly inhibited behavior or by indiscriminate social behavior.

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)

(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)

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).

Specify type:

Inhibited Type: if Criterion A1 predominates in the clinical presentation Disinhibited Type: if Criterion A2 predominates in the clinical presentation

Attachment Disorganization


Two components: Child’s behaviour Caregiver behaviour


Solomon’s (1999) criteria for diagnosis of Attachment Disorganization – Child behaviours

Sequential display of contradictory behaviours Simultaneous display of contradictory behaviours Undirected, misdirected, incomplete, interrupted movements

and expressions Stereotypies, asymmetrical or mistimed movements Freezing, stilling, slowed movements Direct indices of apprehension re. parent Direct indices of disorganization or disorientation


Caregiver atypical behaviours (Lyons-Ruth, 1997; Benoit, 2002)

Affective communication errorsRole / boundary confusionFearful behaviourIntrusiveness / negativityWithdrawal

Test yourself

Attachment security VSAttachment disorganization VSAttachment disorder

What does it look like?

Film clips

What do you think?

What disturbing behaviours can you note that fit a disorganized pattern?

CURRENT HOT TOPICS IN INFANT MENTAL HEALTH

How early difficulties predict later problems and pathologies How environment affects neurobiology How neurobiology affects behaviour- infant and child/adult Attachment patterns and difficulties Regulation difficulties and disorders Interface between neurobiology / regulation / environment

Environment

Neurobiology Temperament

Regulation Caregiver Behaviour

Article reviews

disorders first diagnosed

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