• perceived sense of danger and sends messages to the sympathetic nervous system; fight/flight response- ready body for action
• chemical effects: adrenaline and noradrenaline are released from adrenal glands
• cardiovascular effects: heart rate and strength of the heart beat increase, readying the body for action by speeding up blood flow and improving the delivery of oxygen to the tissues
• respiratory effects: speed and depth of breathing increase, which brings oxygen to the tissues and removes waste. This creates feelings of breathlessness, choking or smothering, or chest pains
• sweat gland effects: sweating increases, which cools the body and makes the skin slippery
• other physical effects: pupils widen to let in more light- creating blurred vision or spots. Salivation decreases- dry mouth, decreased activity in digestive system-nausea and heavy feeling in stomach, muscles tense in readiness of fight or flight- aches, pains, and trembling
• see table 7.1 p.193

• subjective feelings of apprehension, nervousness, difficulty concentrating and panic
• search for potential sources of threat
• difficulty focusing on everyday tasks because of this
• see table 7.1 p. 193

• anxiety: future oriented emotion characterized by feelings of apprehension about upcoming events
• fear: an immediate alarm reaction to current danger or life-threatening emergencies
• panic: a group of physical symptoms of the fight/ flight response that unexpectedly occur in the absence of any obvious threat or danger- present oriented

• many fears are developmentally appropriate and decline with age
• anxieties are also common but do not show an age related decline
• older children report a greater variety and greater complexity of worries- helps prepare for the future
• children with anxiety disorders worry more intensely than those without a disorder
• ritualistic and repetitive is very common and helps them gain control and mastery over their environments

4 of the following for a duration

• excessive distress when separated from major attachment figures
• excessive worry about losing or major harm occurring to major attachment figures
• excessive worry that an untoward event will lead to separation from a major attachment figure
• reluctance to go to school or elsewhere because of fear of separation
• excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
• reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
• repeated nightmares with the theme of separation
• complaints of physical symptoms when separation from major attachment figures 

• most common childhood disorder (10%)
• somewhat more prevalent in girls than boys
• onset may be chronic or sudden
• school refusal, refusal to attend class or, difficulty remaining in school for the entire day
• 2/3 meet criteria for other disorders, 1/2of them will develop depression
• includes test anxiety

• exposure
• behavioral plan
• for kids that refuse to go to school= MAKE THEM GO!!
• coping cat

• person finds it difficult to control the worry
• anxiety is associated with the following:

- restlessness or feeling keyed up on the edge

- difficulty concentrating or mind going blank

- irritability

- muscle tension

- sleep disturbance

• may serve to reinforce behavioral avoidance
• occurs in 3-6% of children
• equal rates in boys and girls
• onset in late childhood or early adulthood
• highly comorbid with other anxiety disorders and depression

• cognitive-behavioral treatment

- isolate maladaptive thoughts and reconstruct them

- provide evidence contrary to their thoughts through exposure

• used for younger children- kindergarten 
• four components:

- recognize anxious feelings and physical reactions

- clarify feelings they are having in the anxiety provoking situation

- develop a coping plan: what is going to help them in the anxiety provoking situation?

- evaluate performance and teach ways to reinforce the good behavior

• extreme fear of particular objects or situations that pose little or no danger
• thought that infants were hardwired with them to protect them from the environment
• most common in children- animals
• 5 subtypes:
• 1. animal
• 2. natural environment
• 3. blood injection/ injury
• 4. situational
• 5. "other"

• persistent fear that is unreasonable and cued by presence or anticipation of an object or situation
• exposure to object/situation provokes immediate anxiety response; make take form from may take place from a situationally-bound or situationally-prone panic attack (in children anxiety can be expressed as crying, tantrums, freezing, or clinging)
• person realizes that the fear is excessive an unreasonable (not necessarily in children)

• Animal: most common is animals- specifically dogs, snakes, insects and mice
• Natural environment: heights, storms, darkness, water
• Blood injection/ injury: seeing blood injections, injury or medical procedures
• situational: flying, elevators, tunnels, bridges, driving
• other: hiccuping, vomiting, fear of numbers

• leads to avoidance or impairments in normal routines
• do not recognize that fears are extreme or unreasonable
• evolutionary theory: infants are biologically predisposed to certain fears that alert them to possible sources of danger
• occurs in 2-4% of all children
• 4-10% met it at some point in their lives
• more common in girls than boys
• most common comorbid disorder is anxiety disorder- which is true of most anxiety disorders 

• most effective= pairing exposure with reinforced practice and response prevention
• graded exposure: generate a list of fears (least to most), and gradually expose- pair with a fear thermometer
• systematic desensitization: teach relaxation, construct fear hierarchy, present anxiety provoking stimuli while child practices relaxation
• flooding: exposure is prolonged and repeated
• response prevention: not allowing escape or avoidance

• marked and persistent fear of being the focus of attention or doing something humiliating
• anxious about mundane tasks (i.e. public speaking or tripping when entering a room)
• more likely to be highly emotional, socially fearful or inhibited, sad and lonely
• generalized social phobia: most severe form: fear of every social situation possible

• Marked fear of one or more social/ performance situations where person if exposed to unfamiliar people or possible scrutiny by others- person fears that s/he will act in a way (or show anxious symptoms) that will be embarrassing or humiliating 
• exposure to the feared social situation provokes 
  • may take form of a situationally-bound or predisposed panic attack
• person realizes fear is unreasonable and excessive (nay be absent in children)
• feared social or performance situation are avoided or endured with extreme anxiety
• more criteria in book

• person recognizes fear is excessive and unreasonable

• recurrent, time-consuming disturbances that cause anxiety
• often accompanied by anxieties that are performed to relieve anxiety
• usually immune to reason
• children try to involve parents in their rituals- rituals don't tend to provide long term relief, so they are repeated often

• exposure and response prevention- can't do their ritual, use fear hierarchy, slow progression
• medication- Luvox is the only FDA approved medication; once medication is stopped, obsessions and compulsions will come right back

• characterized by recurrent and unexpected panic attacks 
• persistent concerns about the implications and consequences of having another attack 
• a sudden and overwhelming period of intense fear or discomfort that is accompanied by physical and cognitive symptoms

4 or more of the symptoms that come on abruptly and reach their peak within 10 mins 

• pounding heart/accelerated heart rate
• sweating
• trembling, shaking
• sensations of shortness of breath
• chest pain/discomfort
• nausea, abdominal distress
• dizzy
• feelings of unreality/detachment
• losing control or going crazy
• dying- fear of
• numbness
• chills or hot flashes

• characterized by persistent anxiety following an overwhelming traumatic event that is outside the range of usual human experience
• core features 
  •  
    • re-experiencing of the traumatic event
    • avoidance of associated stimuli and a numbing of general responsiveness
    • symptoms of extreme arousal

• characterized by the development of dissociative symptoms
• must occur within one month after exposure to an extreme traumatic stressor
• lasts at least 2 days but not longer than 1 month

• excessive anxiety may be related to deficits in memory, attention, speech, and language
• can interfere with academic performance
• Threat-Related Attentional Biases 
  •  
    • engage in negative self-talk

• social withdrawal
• loneliness
• low self-esteem
• difficulty making friends and maintaining friends
• deficits in understanding emotions and understanding the difference between thoughts and emotions

• high comorbitity between anxiety and depression
  • social phobia
  • GAD 
  • separation anxiety disorder
  • less likely in specific phobia
• anxiety usually precedes depression
• share underlying of negative affectivity

• Psychoanalytic
  • view anxieties and phobias as defenses against unconscious conflicts that are rooted in child’s early upbringing
• behavioral/learning
  • fears and anxieties are learned through classical conditioning and maintained through operant conditioning 
• attachment
  • early insecure attachments lead children to view the environment as undependable, unavailable, hostile, and threatening

• low threshold for novel and unexpected stimuli
  • behavioral inhibition
• affected by parental response to anxiety
  • parents who set firm limits and teach their children to cope with stress have better outcomes
  
  

• studies show there is a biological vulnerability to anxiety disorders
• twins studies show that they can have different anxieties, so what is inherited is the disposition to become anxious
• for of the disorder is a function of the environment
• highest genetic influence is ODC and the trait of shyness/inhibition

• Overall Behavioral Inhibition System (BIS)- overactive in anxious individuals
  • HPA system, limbic system, prefrontal cortex, brain stem
  • amygdala
• Neurotransmitters
  • Norepinephrine
  • GABA
  • Neuropeptides
  • Serotonin

• excessive parental control
• prolonged exposure to family dysfunction
• low parental expectations for children’s coping
• Low SES
• insecure early attachments

• feelings of sadness that are more exaggerated and persistent
• irritability, guilt, shame
• symptoms have been known as the “common cold” of psychopathology
• most common
• a lot of the time goes unrecognized and unfortunately untreated
  • children were previously thought to not be able to get it
  • thought that children didn’t have the cognitive capacity to be depressed
  • now know that they have it but they don’t have the ability to express it
  • often overlooked because it co-occurs with other disorders

• restlessness, agitation
• decreases in activity and socialization
• excessive crying
• verbal sarcasm
• destruction
• drug and alcohol abuse to self medicate (adolescence)

• preoccupied with thoughts
• self-critical and self conscious
• difficulties
  • concentrating
  • focusing
  • remembering things
  • making decisions

• eating
  • appetite loss
  • eating too much
• sleeping
  • early morning wakening
  • feeling tired all of the time
• headaches, stomachaches, nausea, aches and pains

• one of the most disabling childhood disorders
• previously not believed to occur
• 5%- children
• 10-20% adolescence
• rare in kids <6
• once an episode occurs, relapse rates are high
  • 25% chance of relapse in one year
  • 50% chance of relapse in two years
  • up to 70% chance of relapse in next five years
• sex differences
  • childhood: M=F or M>F
  • adolescence: F>M
  • *****know for exam!!!!!!*******

• major depressive disorder
• dysthymic disorder
• bipolar disorder (I and II)
• cyclothymic disorder
• depression disorder not otherwise specified

• need 5 of 9 and have to have 1 of the first 2 criteria
• depressed mood most of the day, nearly every day, for at least 2 weeks
  • in children and adolescence, can be irritable mood
• loss of interest in pleasurable activities most of the day, nearly every day, for a least two weeks
• significant weight loss or weight gain, or decrease or increase in appetite nearly every day
• insomnia or hypersomnia nearly every day
• psychomotor agitation or retardation nearly every day
• fatigue or loss of energy nearly every day
• feelings of worthlessness or inappropriate guilt. nearly every day
• diminished ability to think or concentrate, or indecisiveness, nearly every day
• recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, or a suicide attempt or specific plan for committing suicide

• 70% of children and adolescence with MDD have another disorder
• disorders usually precede depression and persist after depression remits
• anxiety, dysthymia, conduct problems, ADHD, and substance abuse

Physiological hyperarousal -> Anxiety <- negative affect -> Depression <- (low) positive affect

• age of onset of first episode usually around 14
• average episode lasts 8 months
• after recovery, reoccurrence is common along with sub threshold symptoms, health problems, chronic stress and adjustment

• depressed mood for most of the day, for more days than not, for at lease 2 years
  • one year for a child
• must be accompanied by 2 or more
  • poor appetite or overeating
  • insomnia or hypersomnia
  • low energy or fatigue
  • low self-esteem
  • poor concentration or difficulty making decisions
• double depression- DD with a major depressive episode

• rates of DD are lower than MDD
• most common comorbid disorder is MDD
• peaks around 11-12 years
  • may be a precursor for MDD
• average episode length= 2-5 years
• most recover but are at high risk for developing other disorders
  • have less social support than other adolescence

• provides the most long- and shirt-term success in children and adults
• also want to change negative attributions
  • internal- blame themselves
  • stable- think that it will never change
  • global- applies to all they do and in most situations
• focus on changing the negative cognitive triad
  • self- there is nothing good about me
  • world- it’s not worth it
  • future- i’ll never be able to graduate

• Primary and Secondary Control Enhancement Training (PASCET)
  • ACT skills- changing objective events (behavioral)
  • THINK skills- altering subjective impact of stress (cognitive)
• Taking Action
  • A= Always find something to do to feel better
  • C= Catch the positive
  • T= Think about it as a problem to be solved
  • I= Inspect the situation
  • O= Open yourself to the positive
  • N= Never get stuck in the negative muck
  
  

• The only SSRI that is FDA approved for treating depression in kids is Prozac
  • Zoloft and Paxil are prescribed “off label” 
    • treating them but there is no research evidence supporting the effects, but there is plenty of evidence for adults
  • lacking info about the development in children

• No completed suicides occurred among nearly 2,200 children treated with SSRI medications
• About 4 percent of those taking SSRI medications experienced suicidal thinking or behavior, including actual suicide attempts
  • The RIsk: Too depressed to actually go out and perform the act of suicide, so when you begin to take the medication, it makes you feel good enough to go out and do so
  
  

• Centers for Disease Control and Prevention reported:
  • suicide rates in young people ages 10-24 were up 8% from 2003 to 2004
  • another study found that during this period, new prescriptions for antidepressants fell, perhaps because of the fears about them
  • don’t know if it is causal, there is just a correlation
• Black Box warning issued- most serious type of warning that the FDA can issue

• 30% of children/adolescence who are clinically depressed attempt suicide by 17 years of age
  • 3rd leading cause of death in 10-14 year olds
• Among children/adolescence who kill themselves, odds of having major depression are 27x more than controls
• Ages 13-14:peak for first suicide
  • Doubled risk for another suicide attempt after the first attempt
• Attempts double in adolescence, but decline after 17-18
• Suicide warning signs- see book

• Low base rate of occurrence- so people don’t even consider it
• Extreme variability in clinical presentation within and across episodes
• Overlap in symptoms with other disorders, especially ADHD
  • Pressured speech: too many thoughts going on that they are forcing all of them out of their mouthes
  • Grandiose beliefs: thought that they could fly, that they are the smartest kid in the world, etc. 
  • Manic symptoms are hard to distinguish from hyperactive and impulsive symptoms of ADHD

• Periods of abnormally and persistently elevated, expansive, or irritable mood, alternating with or accompanied by 1 or more depressive episodes
  • mood states= elation and euphoria
• Irritability and rage
• Silly, giddy, over-excited, over-talkative
  • grandiose beliefs

• 3 or more euphoric, 4 or more irritability- persist for 1 week
  • If needs hospitalization, no time requirements
• Inflated self-esteem or grandiosity
• decreased need for sleep (e.g., feels rested after 3 hours)
• more talkative than usual, or pressure to keep talking
• flight ideas or racing thoughts
• distractibility
• increase in goal-directed activity
• excessive involvement in pleasurable activities that have painful consequences

• One or more manic or mixed episodes and one or more major depressive episodes
• Mixed episode= criteria met for manic and major depressive episode
• Hard for children to have
• More severe and lasts longer

• Numerous hypomanic and depressive symptoms that do not meet full criteria for either a manic episode, mixed episode or major depressive disorder
• In children, must occur for at least 1 year
• No more than 2 consecutive symptom-free months
• Significant distress or impairment in functioning

• Affects .4%- 1.2% of children
• Extremely rare prior to puberty
• Rapid cycling
• More likely to be diagnosed with Bipolar II or cyclothymia
• Affects males and females equally
  • males more likely to have manic, females more likely to have depressive

• Anxiety Disorder
• ADHD Conduct Disorders
• Substance Abuse
• Cardiovascular, metabolic disorders, epilepsy and migraine headaches
  • neurological 
  
  

• Peak age of onset is between ages of 15-19 years
  • extremely rare prior to 10
• depressive episode usually occurs first
• chronic in nature and resistant to treatment
  • the earlier the onset, the more chronic and resistant it becomes
• poor long-term prognosis 
• read in book

• Like Diabetes- once its there it doesn’t go away, but you can manage it and learn to live with it
• Multi-modal
  • Education
  • Medication
    • lithium
  • Therapy
    • social rhythms

• Interference with academic performance
• Cognitive disturbances
  • attributions of failure, ruminative style, negative automatic thoughts, hopelessness
  • negative feelings generalize across situations
• Low or unstable self-esteem
  • might be due to a poor body image
• Social problems
  • few friends, feelings of loneliness and isolation, ineffective coping styles, social withdrawal
  • families characterized as less supportive, conflict ridden, socially isolated from family
• Poor interpersonal relationships
  • conflict with parents and siblings
• Suicidal thoughts
  • 16-30% attempt
  • strongest risk factors: being a female and having a mood disorder

• depression results from the actual or symbolic loss of a love object
• viewed depression as the conversion of aggression into inward ange

• focuses on parental separation and disruption of a secure attachment bond as predisposing factors of depression

• Emphasis on the importance of learning, environmental consequences (lack of response contingent positive reinforcement)
• Skill deficits

• Focus on the negative perceptual and attributional styles and beliefs
  • negative information processing: only look for the negative aspects of the world
  • negative automatic thoughts
  • internal, stable, and global attributions for the causes of negative events
  • negative cognitive triad- negative outlook about oneself, the world, and the future
  • negative cognitive schemata
  
  

• Moderate genetic influence
  • heritability estimates range from .35-.75 across twin studies
• family and twin studies
• what is actually inherited is the vulnerability to depression and then the environmental stressors will bring them out

• Children with depression may have heightened reaction to stress (frontal lobe)
• HPA axis, amygdala, hippocampus, sleep architecture (abnormal EEGs), growth hormone and neurotransmitters may be involved 
  • seratonin, dopamine and norepinephrine

• Children are at risk if they have....
  • families with more anger, conflict, disorganization, and over- involvement/ control. poorer communication, high stress levels, and less warmth and support
  • parental depression (more likely for children before puberty)
  
  

• Increases in stress associated with increases in depression
  • moving
  • birth of a sibling
  • death of a loved one
  • changing schools
  • parent conflict or divorce
  • family violence
  • lack of family resources
  • serious accident or family illness
• see triggers in book

• Children who have...
  • problems regulating negative emotional stress
  • difficulty overcoming negative moods who then use avoidance and negative behavior to regulate distress
• are more prone to depression