Chariny Herring, DO Board Certified Child and Adolescent Psychiatrist

Downstairs Upstairs

Hindbrain The earliest portion of our brains; it contains aspects (e.g., a brainstem, cerebellum, and hypothalamus) that we share with other animals, including reptiles. Portions of the brain in the reptilian complex govern our most basic life functions (e.g., hunger, breathing) and primitive survival instincts (e.g., fight or flight). When survival becomes threatened, this part of the brain takes over and can overpower logic and reason.

Midbrain The next most recent development in the human brain, contains aspects (e.g., a limbic system and hippocampus) that we share with other mammals. This complex governs our higher emotions, such as separation distress and playfulness, and grants us the ability to socialize and communicate with one another.

Cerebral Cortex

Largely comprised of the cerebral cortex, is the most recent addition to the human brain and is believed to govern our logic and higher reasoning functions. This is the area of the brain that allows us to do math and science and to solve complex problems through reason.

The relationship

between dogs and their

owners is very similar to

the bond between young

kids and their parents

Dogs and children seem to share what is known as the “secure base effect”. This

effect is seen in parent-child bonding as well as the bond between humans and dogs.

This refers to the idea that when human infants interact with the environment, they

use their caregivers as a secure base.

Lisa Horn et al, Department of Cognitive Biology, University of Vienna, Austria, 2013

Do you know what you see,

or do you see what you know?

Separation Anxiety Disorder

Generalized Anxiety Disorder

Social Phobia

Specific Phobia

Panic Disorder

Selective mutism

Obsessive Compulsive Disorder

Post Traumatic Stress Disorder

Katja Beesdo, PhD, Susanne Knappe, Dipl-Psych, and Daniel S. Pine, MD

Psychiatry Clinics of North America. 2009 Sep; 32(3): 483–524.

The lifetime

PREVALANCE of

“any anxiety

disorder” in studies

with children or

adolescents is about

15% to 20%

20%

The HPA axis. Black line- Suppression connection; dotted line- Facilitory

connection; dots and dashes line- Suppression connection indirect pathway (via

BNST and other limbic regions); and dashed lines- Facilitory connection indirect

pathway (via BNST and other limbic regions).

Biological

PsychologicalSocial

School

peers

Family

circumstances

Family

relationships

Trauma

Drug

effects

Physical health

disability

genetic vulnerabilities

temperament

IQ

Coping skills

Social skills

Self-esteemMental

Health

Biopsychosocial

Model of Health

Genetic Influences

• Biological vulnerability to inherit a fearful disposition/temperament

• ie: irritable, shy, cautious, quiet

Neurobiological factors

• Within the limbic system, the behavioral inhibition system is overactive (larger, stronger)

Neurochemical factors

• Abnormal function of serotonin, norepinephrine, dopamine, and GABA

• among child, family, and other environmental factors

• child temperamental characteristics (i.e., behavioral inhibition) X insecure parent-child attachment X anxious and controlling parenting styles

Bidirectional Relationships

• physical, sexual, psychological abuse, exposure to DV, community violence, natural disasters

Trauma Exposure (abuse and violence)

• children learn about anxiety-provoking situations by

• observing others experience of such situations (parental modeling of fear responses)

• acquiring information through activities like reading or watching the news on television

Observational Learning

Cognitive

Physical

Behavioral

Anxious thoughts develop in response to cognitive distortions in the attention, interpretation, and memory components of information processing

Selective memory processing

Tendency to remember anxiety-provoking cues/experiences

Attention biasesToward threat-related information. Selectively attend to information that may be potentially threatening

Distorted Judgements

Risk/Cognitive biases

Perfectionistic beliefs

Inflated sense of responsibility

Negative spin on ambiguous/non-threatening situations lead them to select avoidant solutions

What if statements

Marked degree of subjective distress and excessive

worry about things including:

the appropriateness of past behavior

possible injury or illnesses (to themselves or

others)

the possibility of major calamitous events

ability to live up to expectations

competencies in various areas

being accepted by others

other things related to concerns about the

future

Physical Acute: brain sends messages to sympathetic nervous system: fight

or flight response

Chronic: headaches, upset stomach sleep disturbance, aches/pains

Action (or inaction) that individuals take to prevent exposure to feared stimuli or to reduce anxiety associated with exposure to the feared stimuli

• Low self-esteem

• Refusal to speak

• Loneliness

• Perfectionistic

• Excessive approval seeking

• Frequent solicitations of reassurance

• Interference with academic performance, school avoidance

• Nail biting, hair pulling (head hair, eyelashes, eyebrows), chewing on shirts, wringing hangs, skin picking

• Outbursts of mood dysregulation/tantrums

• Aggression/anger

Screen for Child Anxiety Related Disorders (SCARED)

Parent and Child versions

https://www.ohsu.edu/sites/default/files/2019-06/SCARED-form-

Parent-and-Child-version.pdf

An executive function is a neuropsychological concept referring to the cognitive processes required to plan and direct activities, including task initiation and follow through, working memory, sustained attention, performance monitoring, inhibition of impulses, and goal-directed persistence. (Dawson & Guare, 2004, p. vii)

Inattention

(1) often fails to give close attention to details or makes careless mistakes in

schoolwork, work, or other activities

(2) often has difficulty sustaining attention in tasks or play activities

(3) often does not seem to listen when spoken to directly

(4) often does not follow through on instructions and fails to finish school-work, chores,

or duties in the workplace (not due to oppositional behavior or failure to understand

instructions)

(5) often has difficulty organizing tasks and activities

(6) often avoids, dislikes, or is reluctant to engage in tasks that require sustained

mental effort (such as schoolwork or homework)

(7) often loses things necessary for tasks or activities (e.g., toys, school assignments,

pencils, books, or tools)

(8) is often easily distracted by extraneous stimuli

(9) is often forgetful in daily activities

Hyperactivity -Impulsivity

(1) often fidgets with hands or feet or squirms in seat

(2) often leaves seat in classroom or in other situations in which remaining seated is

expected

(3) often runs about or climbs excessively in situations in which it is inappropriate (in

adolescents or adults, may be limited to subjective feelings of restlessness)

(4) often has difficulty playing or engaging in leisure activities quietly

(5) is often "on the go" or often acts as if "driven by a motor"

(6) often talks excessively

(7) often blurts out answers before questions have been completed

(8) often has difficulty awaiting turn

(9) often interrupts or intrudes on others (e.g., butts into conversations or games

Combined hyperactive-impulsive and inattentive (50-75%)

Predominantly Inattentive (20-30%)

Predominantly Hyperactive/Impulsive (<15%)

6 or more of the previously noted symptoms persisting for 6 months or longer qualifies for a diagnosis of ADHD in either the inattentive category or hyperactivity-impulsive category.

One of the symptoms needs to have been present before the age of 12.

Some impairment from the symptoms is present in two or more settings, such as school or home.

There must be clear and significant evidence of a social, academic, or occupational impairment.

The symptoms are not better accounted for by another mental disorder.

5-10% of child/adolescent population

Accounts for 30-50% of child referrals to mental health

services

Males : Females 4:1

Learning Disorders Hypoglycemia/Diabetes Hypo/hyperthyroidism Allergies Hearing/vision problems Toxicity (lead, mercury) Epilepsy Nutrient deficiencies Anemia Sensory Disorder Medication adverse effects

Antiasthmatics Anticonvulsants Benzodiazepines Antihistamines

Excessive caffeine

Anxiety disorders

Bipolar/depression

Intellectual Disability

Trauma/PTSD

Attachment disorders

Sleep disorders

Infections

Pain

Traumatic Brain Injuries

Fetal Alcohol Syndrome

Substance abuse

Adjustment Disorder

Almost 75% of individuals with ADHD have a psychiatric comorbidity: Conduct Disorder (10-20%)

ODD (54-84%)

Substance Abuse (40%)

Anxiety Disorders (30-40%)

Learning Disorders (33-60%)

Tic Disorders (34%)

Depression (15%-30%)

Bipolar Disorder (15%-20%)

Sleep Disorders (30%-75%)

Shared Features: Impaired concentration

Impaired attention/memory

Difficulty with task completion

Distinctive Features Anxiety: concentration, attention, memory, task completion

improve in a lower stress environment

Anxiety often includes a physical presentation

Dysphoria with anxiety is more persistent than ADHD

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness

lasting at least 6 months as evidenced by at least four symptoms of the following

categories, and exhibited during interaction with at least one individual who is not a

sibling:

Angry/Irritable Mood1.Often loses temper

2.Is often touchy or easily annoyed

3.Is often angry and resentful

Argumentative/Defiant Behavior4.Often argues with authority figures or, for children and adolescents, with adults

5.Often actively defies or refuses to comply with requests from authority figures or with rules

6.Often deliberately annoys others

7.Often blames others for his or her mistakes or misbehavior

Vindictiveness8.Has been spiteful or vindictive at least twice within the past 6 months.

Younger than 5 years: the behavior should occur on MOST days for a period of at least 6 months

5 years or older: the behavior should occur at least 1x/ week for at least 6 months.

Severity rating: ◼ 1 environment: mild

◼ 2 environments: moderate

◼ >2 environments: severe

Disruptive behavior disorders occur in 2.8% of school-age children

Prevalence rates fall in late childhood and adolescence As child ages, symptoms may develop into CD

No gender differences between ages 1-8

Aggression typically expressed verbally rather

than physically.

Can be linked to authoritarian and

permissive/indulgent parenting

Can be associated with difficult temperament

and or frustration resulting from unmanaged

co-morbidities

James H. Johnson, PhD

Faisal Ahmed, M.D

C. Carolyn Thiedke, MD

S. Steve Snow. MD

Doug Emch MD

Gabriel Kaplan, MD

Bennett Silver, MD

Jess P. Shatkin, MD, MPH

Sucheta D. Connolly, MD

Katja Beesdo, PhD, et al

Larry Scahill MSN, PhD

Doug Emch MD

Mary Schwab-Stone, MD

Elizabeth I. Martin, PhD,

Kerry J. Ressler, MD, PhD

Elisabeth Binder, MD, PhD

Charles B. Nemeroff, MD, PhD

Inpatient Care: Life threatening situation (SI/HI or inability

to care for self)

Acute

RTC

Intensive OP(IOP)/ Partial Hospitalization

Wrap Around Services/Systems of Care

Community Mental Health Center

Academic Outpatient Centers

Private practice options