Chariny Herring, DO
Transcript of Chariny Herring, DO
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