Final Exam Sections - 1 Running Head: FINAL EXAM SECTIONS

APSY 651 Final Exam Section One: Attention Deficit/Hyperactivity Disorder Co-Morbidity in Childhood Disorders Rhonda Williams University of Calgary

Final Exam Sections - 2 One of the issues I found interesting in this Child Psychopathology course was the prevalence of Attention Deficit/Hyperactivity Disorder (ADHD) co-morbidity with a wide range of childhood disorders. Presentation after presentation talked about the co-occurrence of ADHD with both internalizing and externalizing disorders. This peaked my curiosity and prompted me to further explore the prevalence of ADHD co-morbidity with the childhood disorders presented in the Mash and Barkley (2003) textbook. It seems the presence of ADHD draws attention to children who may also have other psychiatric disorders. Externalizing disorders such as ADHD, Oppositional Defiant Disorder (ODD) and Conduct disorder (CD) more readily elicit intervention by caregivers because the impact on daily functioning can be easily observed by others. Working in a school designed to address the academic, behavioural and social/emotional needs of children with one or more psychiatric disorder, I have also seen a high prevalence in the diagnosis of ADHD with a variety of disorders. It makes me wonder if ADHD is commonly the first disorder to be identified while other diagnoses tend to follow as children get older. How many other disorders could be identified at an earlier age? Do professionals and caregivers tend to stop investigating after ADHD has been identified or does other symptomology present itself as a child ages? I wonder how many girls go undiagnosed because they tend not to demonstrate as many externalizing behaviours. When looking at the population within our specialized setting, a gender difference in relation to types of disorders represented is distinctly apparent. There is a huge over-representation of boys presenting with externalizing behaviours in our classes. Typically each class of approximately 12 students only has one or two girls in it. Many times there are classes without any girls for a greater part of the year. However, as you look at higher grades, the gender difference seems to minimize, although there is still a higher number of boys. Girls that attend these classes are more likely to be diagnosed with anxiety or mood disorders and also engage in high risk activities (e.g. self-harming behaviours, sexual promiscuity and substance abuse). I wonder how long many of these girls flew

Final Exam Sections - 3 under the radar in community schools until their behaviours became more overt, prompting a response by professionals and caregivers. Perhaps if these girls were identified sooner, they may not have required the intense intervention our school provides. I think ADHD may be overrepresented as co-morbid with childhood disorders and that more research needs to be done to investigate the role of co-morbidity in the diagnosis and treatment of childhood disorders in general. In this paper I will explore the co-morbidity of ADHD with a diverse range of other diagnoses and how this knowledge will impact my practice with children, adolescents and other professionals. (Do you think its possible that the popularity of ADHD symptomology makes more teachers aware of it and therefore, more likely to refer students for assessment? By the same token, might there be other disorders that are less well-known that do not get diagnosed or identified simply because people in general are not aware of them?) Co-morbidity has proven to have an important impact on defining and classifying childhood disorders. In general, co-morbidity refers to two or more disorders that co-occur more often than they would by chance alone in the general population. Co-morbid childhood disorders tend to occur more often than pure diagnostic profiles (Mash & Barkley, 2003). This makes it difficult to draw meaningful conclusions about characteristics used in the diagnosis, underlying constructs and treatment for a particular disorder. When looking at a potential diagnosis of ADHD for a child, ADHD should not be diagnosed if the symptoms can be better accounted for by another disorder such as mood disorders (especially bipolar disorder), anxiety disorders, dissociative disorder, personality disorder, personality change due to a general medical condition, or substance-related disorder (APA, 2000). Through my experience working with students diagnosed with at least one disorder, ADHD tends to be a common first diagnosis given at a young age. Many times another disorder will become more prevalent as the child gets older and the ADHD symptoms could be described by another diagnosis. Typically the ADHD diagnosis does not get removed and an

Final Exam Sections - 4 additional diagnosis is added. I have observed this pattern many times with students diagnosed with a Pervasive Developmental Disorder (PDD). When these students are younger, their behaviour warrants an ADHD diagnosis. However, as they become older and get closer to adolescence, these students exhibit more social dysfunction resulting in a PDD diagnosis. The DSM IV-TR (APA, 2000) specifically states that ADHD should not be diagnosed if the symptoms of inattention and hyperactivity occur exclusively during the course of a Pervasive Developmental Disorder or a Psychotic Disorder (p. 91). I question why the ADHD diagnosis is not later removed when many of the symptoms observed at a younger age can now be explained by a PDD diagnosis. It seems that many psychologists are hesitant to remove the ADHD diagnosis previously identified even though the DSM IV-TR clearly states parameters for this situation. (I wonder if its a matter of

the clinician covering all bases even though, as you point out, the exclusionary component of the PDD diagnosis would appear to rule out ADHD in some cases) Research has shown that ADHD has a high rate of co-morbidity with other childhood disorders. In community-derived samples, up to 44% of children diagnosed with ADHD have at least one other disorder and 43% have at least two or more additional disorders. This rate is even higher in clinical samples where as many as 87% are diagnosed with at least one other disorder and 67% have at least two or more additional disorders (Mash & Barkley, 2003). ADHD is more frequently diagnosed in males than in females, with the male-to-female ratio ranging from 2:1 to 9:1, depending on the type (less pronounced gender difference in the Predominately Inattentive Type) and setting (high rates of males in clinical studies) (APA, 2000). ADHD has been found to most commonly be co-morbid with Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) but also shows levels of co-morbidity with Mood Disorders, Anxiety Disorders, Learning Disorders, Mental Retardation and Substance-Use Disorders. In fact, when looking at the textbook,

Final Exam Sections - 5 only three of the topics covered (Austism, some Anxiety disorders, Schizophrenia and Eating Disorders) did not discuss co-morbidity with ADHD. Oppositional Defiant Disorder and Conduct Disorder A strong association with conduct and antisocial disorders such as CD and ODD has found a diagnosis of ADHD to be one of the most reliable predictors of the occurrence of these disorders. In fact, between 54-67% of children diagnosed with ADHD will meet the criteria for an ODD diagnosis by 7 years of age or older. The co-occurrence of CD with ADHD may be as high as between 20-50% in children and 44-50% in adolescents (Mash & Barkley, 2003). There can be a progression from ADHD to ODD or ODD to CD when the severity of psychopathology progresses with the introduction of oppositional behaviour and aggression. However, this does not mean a child diagnosed with any of these disorders will experience co-morbidity with the others. There is not necessarily a causal relationship despite the predictive power of ADHD. Research has found there are underlying causal connections between these disorders when looking at familial association. In particular, shared or common genetic contributions have been found between ADHD, ODD and CD; especially ADHD and ODD. The greater the genetic loading for ADHD, the more severe the ADHD symptoms and the more likely the child will be later diagnosed with Conduct Disorder. Family adversity and impaired parenting are also risk factors that greatly impact all three disorders (Mash & Barkley, 2003). Mood Disorders Mood disorders have also been identified to co-occur with ADHD despite being an internalizing disorder. The co-morbidity rate of ADHD with mood disorders such as major depression or dysthymia ranges between 15-75% (averaging between 20-30%)(Mash & Barkley,

Final Exam Sections - 6 2003). (as noted in classthis is a somewhat distressing statistic that speaks to the challenges with making appropriate diagnoses 15-75% is a HUGE range!)Both community and clinical samples have shown an increased co-morbidity between depression and ADHD. Faraone and Biederman (1997; as cited in the Mash and Barkley, 2003) reviewed family studies and argued that both ADHD and depression share a genetic predisposition. They also share risk factors such as parental depression and parental marital/couple conflict. Typically, depression usually follows the onset of a behavioural disorder. Again gender differences influence the co-morbidity of depression. Depressed girls have a higher rate of co-morbidity of anxiety disorders, while depressed boys have a higher rate with ADHD and disruptive behaviour disorders. Socialization plays a part in how each gender expresses themselves with boys generally more external in their expressions, while girls tend to be the opposite. This trend can be observed from a young age in the way adults act with children. Although very interesting, gender socialization is beyond the scope of this paper but it is an area I am also interested in. The co-morbidity of ADHD and depression is congruent with my observations throughout my career. Often the presence of an externalizing disorder such as ADHD (to a further extent ODD and CD) creates stressful disruptions in family, school and social aspects of the child`s life, creating conflict with others. This isolates children and many appear lonely and want to feel connected but pursue this in maladaptive ways. Without teaching more prosocial skills in a consistent and stable environment, these children tend to revert back to previous behavioural patterns regardless if it was working or not. I can see why these children would eventually become depressed. Anxiety Disorders Anxiety Disorders have also shown co-morbidity with ADHD ranging from 10-40% in clinically referred children (averaging 25%)(Mash & Barkley, 2003). Most studies of co-morbidity

Final Exam Sections - 7 focus on the Combined Type (ADHD-C) and Predominately Hyperactive-Impulsive Type (ADHDPHI) of ADHD. However, Anxiety Disorders seem to reduce the degree of impulsivity when comorbid with ADHD. Higher rates of co-morbidity with anxiety disorders have been linked to ADHD Predominantly Inattentive Type (ADHD-PI) where there may be a genetic link. However, no genetic link has been found with both ADHD-C and ADHD-PHI and Anxiety Disorders. When externalizing disorders are co-morbid with Anxiety Disorders, certain types of anxiety can be a protective factor while others can heighten the risk of physical aggression. The presence of inhibition and fear anxiety symptomology seems to be a protective factor, while the presence of social withdrawal seems to put children at a higher risk to engage in conduct behaviours such as physical assaultive and antisocial behaviour. Being aware of these factors can help professionals, like myself, to be more aware of specific behaviours and prompt us to intervene prior to the escalation of conduct behaviours. Although there is not a direct causal link between ADHD and ODD/CD, I do think we should be very cautious and watch for specific indicators that a child with ADHD could develop ODD and CD. ADHD seems to be the gateway disorder to many other things...at least, it brings our attention to many other things. (possibly due to the fact that once identified, the student is significantly more likely to be working with professionals who have experience with mental healthy issues)Our duty as a specialized school setting is to be mindful of our observations. The more information we have regarding the co-morbidity of ADHD and potential protective and risk factors, the more effective we will be regarding early intervention. Many things get explained away as ADHD symptoms until children get older and are better able to articulate their inner states of being or begin displaying more harmful behaviours. The underutilization of mental health services tends to happen more frequently with internalizing symptoms such as Anxiety and Mood Disorders. Externalizing disorders tend to be noticed more frequently by caregivers and are perceived to have a greater impact on daily functioning. Children

Final Exam Sections - 8 with internalizing disorders seem to suffer in silence because they are not as easily identifiable, resulting in a failure to recognize and intervene early in the development stage of these disorders. Tic Disorders Tic disorders have an interesting co-morbid relationship with ADHD. There is a Berkson`s bias (co-morbidity with ADHD leads to clinical referral despite having independent risk factors) when it comes to Tourette`s disorder and other tic disorders. ADHD does not have a significant co-morbid rate with Tourettes. However, Tourette`s disorder has a 48% or greater chance of co-occurrence. The Berkson`s bias may explain this phenomenon because a child with ADHD symptoms will more likely lead to a clinical referral bring to light Tourette`s disorder or other tic disorders (Mash & Barkley, 2003). This is an interesting example of how co-morbidity can occur but not have a causal relationship. It seems if a child has the good fortune of being diagnosed with ADHD at an earlier age, they have a better chance of receiving help for other psychopathology. How many children go unnoticed? Mental Retardation (Intellectual Disabilities) Children diagnosed with Mental Retardation (MR) have a high rate of psychiatric disorders or behavioural and emotional problems when compared to their non-retarded peers. However, many psychiatric categories cannot be easily applied to children with intellectual disabilities. Temper tantrums, physical aggression, impulsivity, hyperactivity and diminished responsiveness to others are commonly exhibited by children diagnosed with MR (Mash & Barkley, 2003). Although these behaviours can be severe, they do not necessarily indicate co-morbidity with another psychiatric disorder such as ADHD. The mental age, rather than the chronological age, of the child must be taken into consideration. For an intellectually disabled child with a mental age of 2 or 3,

Final Exam Sections - 9 ADHD-like behaviours may be developmentally appropriate despite having a chronological age of 14. Consideration of the child`s mental age has been specifically addressed within the diagnostic criteria for ADHD (APA, 2000). Since it is difficult to diagnose ADHD in children younger than 4 or 5 because of their developmental characteristics, it would make sense that it would be difficult to diagnose a MR child with ADHD if their mental age is younger than 4. Efforts are being made to propose an alternative diagnostic criteria for children diagnosed with MR has been normed on mentally disabled children rather than ``normal`` samples to help distinguish whether other comorbid disorders such as ADHD are present.

Learning Disorders There is moderate co-morbidity between ADHD and Learning Disorders. Between 19-26% of children with ADHD are likely to have at least one type of learning disability; reading disorder (1639%), spelling disorder (24-27%), and mathematics disorder (13-33%). The majority of individuals diagnosed with a reading disorder are male (60-80%)(Mash & Barkley, 2003). Many children diagnosed with ADHD also have disorders of written expression due to motor and executive functioning problems. However, these findings may reflect a referral bias because males tend to more frequently display disruptive behaviour (externalizing behaviours) in association with a Learning Disorder. As found with other externalizing disorders, these children tend to be identified more readily by caregivers and receive mental health services. Gender rates tend to equal out when more stringent criteria is used rather than traditional school based referrals and diagnostic procedures (Mash & Barkley, 2003). The area of learning disorders has been a huge component to the work we do in our school. Many times students have missed so much instruction time due to the inability to focus in class. Often teaching practices have struggled to find ways to engage the

Final Exam Sections - 10 ADHD child. By the time the student reaches junior high, the gaps in knowledge become even more evident and students become disenfranchised. However, once effective learning strategies have been implemented and medication is prescribed for those who choose it, these students tend to flourish and gain confidence in their academic abilities. Understanding Learning Disorders and their co-morbidity with ADHD is very important in the school setting. Early intervention is key to creating supportive learning environments that may minimize the impact of learning disabilities. As the field of education shifts towards the personalization of learning, these students will be able to focus on their interests and strengths rather than learning is a specific way that may not meet their individual needs. It will be interesting to see how our assessment practices and diagnostic criteria will adjust to the 21st Century learner. Struggles with Co-morbidity in Childhood Disorders There are several reasons why co-morbidity may be exaggerated or artificially produced within child psychopathology. Often clinic samples are used to measure the rates of co-morbidity. This sampling bias may contain a disproportionate amount of children with a co-morbid disorder because the likelihood of being referred to mental health services is higher when a child has more than one disorder. Referral factors may also inflate the rate of co-morbidity in clinic samples. In order to understand the true co-morbidity of a disorder, community samples should be used to gain a more accurate reading regarding mental health disorders. Children exhibiting externalizing behaviours may be referred more frequently because these behavioural problems are seen as more disruptive and impactful on the childs overall level of daily functioning. Another problem with comorbidity is the overlap of symptom criterion. The current categorical nature of the DSM IV-TR allows for accompanying symptoms to be represented in more than one area. Some symptoms can be seen under more than one disorder. It is the poor or ambiguous definitions of mental health

Final Exam Sections - 11 disorders that contribute to widespread co-morbidity across many different disorders, especially when looking at the range of disorders that are co-morbid with ADHD. Specifically, there is substantial overlap between the symptomology of ADHD, ODD and CD. However, this overlapping can indicate the severity of child psychopathology for the child. For example, the presence of both ADHD and CD displays a far more detrimental form of psychopathology than either disorder on its own. These children demonstrate higher rates of physical aggression, antisocial behaviour, peer rejections and lower academic achievement. The co-morbidity of ADHD and physical aggression is strongly associated with the early onset of conduct problems in children(Mash & Barkley, 2003). Finally, developmental progression should also be taken into consideration when looking at co-morbidity. Lilienfield et al. (1994; as cited in Mash & Barkley, 2003) maintain that co-morbidity in childhood disorders may be partly due to developmental levels. Co-morbidity rates also seem to change as children get older indicating that in some instances one disorder may precede the development of another disorder. This seems to be the case with anxiety preceding depression or for impulsivity preceding attentional difficulties. My Thoughts and Course of Action... This course has helped me to further formalize my thoughts regarding what I have observed in my career working with special needs children and adolescents over the last 10 years. It has strengthened my base understanding regarding childhood psychopathology and exposed me to current research in a plethora of areas. The prevalence of ADHD co-morbidity with a variety of internalizing and externalizing disorders become more prominent as the presentations and chapter readings progressed in the course. By comparing the relationship between ADHD and various other disorders, I believe it has made me more aware of other symptomology front line workers such as teachers and counsellors should be conscious of when working with youth. It has brought to light

Final Exam Sections - 12 the overrepresentation of externalizing disorders in our childhood intervention practices. It seems a child needs to start impacting the lives of those around them before they will receive mental health services. This paper has prompted me to want to further investigate what early intervention practices could be put in place to help identify other psychopathology in addition to ADHD at a younger age. I also would like to read more research on the early identification and assessment of internalizing disorders in children. My work at the school seems to be so reactive in nature. Things have gotten so carried away for these children that they are removed from their community schools and placed in our setting. I feel that more could be done way before the child requires or setting. I would like to find ways to be more proactive within our system. Part of what needs to happen is professionals who understand child psychopathology (e.g. specialists, special education teachers, school psychologists, counsellors, etc.) need to teach other professionals in our school systems how to service high needs children with psychiatric disorders. It is through this professional collaboration information will be shared and more proactive approaches will be designed for students. When looking at the diagnoses of our students, I will now be looking at the ADHD diagnosis with a different lens. I will more closely look at what other diagnosis are present and if there are potential genetic factors at play. I will also be observing more closely for internalizing disorders, especially in our younger students. This course has built on my practical knowledge and allowed me to deepen my understanding in so many ways. It has made me a better administrator and hopefully a better practitioner in my future career goals.

Final Exam Sections - 13 -

Running Head: FINAL EXAM SECTIONS

APSY 651 Final Exam Section Two: Comparisons Between Social Phobia and Substance Use Disorders Rhonda Williams

Final Exam Sections - 14 University of Calgary

Throughout the progression of this Child Psychopathology course, the relationship between internalizing and externalizing childhood disorders has been very interesting to me. A huge portion of students within the specialized school setting I work in have multiple diagnoses. It is often the severity of the externalizing behaviours that are the salient reason for referral to our program despite the co-morbidity of internalizing disorders for a significant portion of the students. For this second section of the final exam, I wanted to explore Substance Use Disorders and Social Phobia. Substance Use Disorders are more prevalent in our junior and senior high school classes and have a huge impact on the daily functioning of our students. In fact, we have a few students who bounce in and out of treatment programs and court ordered secure services because of their struggles with substance use. In our student population I also suspect Social Phobia is being under-reported and perhaps masked by other, more overt disorders. I wanted to learn more about each of these areas and chose this assignment as a way to take the time to explore what I am curious about. (good topic selection I agree that there is a great deal of undiagnosed Social Anxiety kids out thereadults too!) In this paper I will explore the typical features for both Social Phobia and Substance Use Disorder. I will also identify and compare some of the diagnostic challenges and the impact sociodemographic factors such as gender and socioeconomic status (SES) have on both disorders.

Final Exam Sections - 15 Typical Features Although Anxiety Disorders are widely recognized as one of the most common psychiatric disorders impacting children and adolescents, many aspects still need to be uncovered regarding how it effects youth. In general, anxiety disorders have a negative impact on psychosocial factors such as academic performance, family functioning and social functioning. They also have an early onset in childhood and adolescence and run a chronic course well into adulthood. There are nine different forms of Anxiety Disorders currently categorized within the DMS IV-TR (APA, 2000) including Separation Anxiety Disorder, Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Social Phobia, Specific Phobia, Obsessive Compulsive Disorder, Posttraumatic Stress Disorder, and Acute Stress Disorder. Social Phobia in children and adolescents is identified by a marked and persistent fear of one or more social or performance situations in which the person fears embarrassment, rejection or humiliation. When exposed to the social situation, the child immediately experiences an anxiety response that may take the form of a panic attack. Children with social phobia tend to either avoid the situation or endure with extreme distress. Due to the cognitive developmental limitations of children and adolescents, the child may not view their reactions as unreasonable and excessive to the stimulus, although this stipulation is required when diagnosing adults. The core symptoms of Social Phobia must be present for at least 6 months and cause significant impairment in daily functioning or marked distress to be diagnosed as a psychiatric disorder. Subtypes within Social Phobia for children and adolescents are only just beginning to receive research attention. A Social Phobia diagnosis can also be specified as Generalized if the fears include most social situations, although an additional diagnosis of Avoidant Personality Disorder should also be considered.

Final Exam Sections - 16 The Generalized subtype is the most common form of Social Phobia for children and adolescents. Specifically, adolescents with Generalized Social Phobia have an earlier age of onset, greater impairment in functioning, higher risk for the development of co-morbid conditions, and a greater likelihood of earlier inhibited temperament or family adversities. Children and adolescents with Social Phobia often have few friends, hesitant to join group activities, and often express feelings of loneliness. They are usually considered shy and quiet by their peers and families. Within the school setting, youth diagnosed with Social Phobia are extremely fearful of a wide range of situations such as public speaking or reading aloud, asking for teacher assistance in front of others, unstructured peer encounters, gym activities, group collaboration, taking tests and eating in public areas. Often these children are viewed as loners and have a tendency to spend unstructured class time by themselves or with one specific friend. Participation in extracurricular activities and parties requires strong encouragement from others and avoidant behaviours can even happen with family situations. Adolescents with Social Phobia tend to delay experiencing age-specific developmental events such as dating and getting a job because of their avoidance of social situations. They often think if themselves in a negative and self-deprecating manner, frequently experiencing somatic complaints such as stomach aches and illness. As children get older, they become more worried about the physical manifestations of fear such as excessive blushing or shaking during public speaking, an unsteady voice or sweating, and someone noticing these symptoms. Social Phobia is most often diagnosed in adolescents but can occur earlier in childhood. Children with Social Phobia present with a significantly higher depressed mood compared to normal children, feel less confident, and are more anxious. Adolescents tend to be emotionally over-responsive and more fearful with impaired social skills. Drawing attention to themselves, especially in front of their peers, is avoided at all costs. This fear can become so pronounced that adolescents may even start

Final Exam Sections - 17 avoiding school altogether. The beginning of junior high can be especially challenging when students are required to adapt to multiple teachers, busy hallways during class changes, using lockers and participate in group projects. It is during this time the detrimental impact on school functioning can become more evident for adolescents with Social Phobia, resulting in the involvement of mental health services. Social Phobia is found to be co-morbid with other Anxiety Disorders, Mood Disorders, Substance-Related Disorders, and Bulimia Nervosa. Substance-Related Disorders have been an issue of concern in child psychopathology for many years. Although numerous adolescents experiment with substance use without major negative consequences, others can become addicted either physiologically or psychologically. SubstanceInduced Disorders and Substance Use Disorders are recognized as two classes under the umbrella Substance-Related Disorders within the DSM IV-TR (APA, 2000). Substance-Induced Disorders result from exposure to or ingestion of a substance (e.g. Substance-Induced Psychotic Disorder and Substance-Induced Delirium). Substance Use Disorders identify the maladaptive use of a substance such as drugs and alcohol, and can be divided into Substance Abuse and Substance Dependence criteria. Although Substance Abuse is considered to be less severe, it is the most common diagnosis given to adolescents. There are 11 different types of substances recognized within this disorder including alcohol, amphetamine, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine (PCP), and sedatives (including hypnotics and anxiolytics). To be diagnosed with Substance Dependence, the adolescent must be engaging in a maladaptive pattern of substance use for at least 12 months with the presence of three or more behavioural, cognitive, and/or physiological symptoms. Issues of tolerance, withdrawal, and psychological dependency define core symptoms within Substance Dependence. Tolerance refers to when an increased amount of the substance is to required to attain intoxication, as well as when

Final Exam Sections - 18 the consuming the same amount of substance no longer produces a similar effect. Withdrawal occurs when the individual experiences cognitive and physiological changes after discontinuing the use of a substance or when the same substance is taken to relieve or avoid withdrawal symptoms. The psychological factors required for diagnosis include taking a greater amount of the substance than was intended, large amounts of time used to obtain, use or recover from the substance, negative impact on the involvement in other activities, and continued substance use despite knowledge of its negative impact. This diagnosis can also be made in the absence of physiological factors (tolerance and withdrawal) and is specified as such, as long as there is still the presence of three psychological factors. A diagnosis of Substance Abuse requires the adolescent to exhibit at least one or more harmful and negative consequences during a 12 month period that does not qualify under the Substance Dependence criteria. These harmful and negative consequences include: a) failure to fulfill major role obligations at school, work, and home; b) continued use of substances in hazardous situations (e.g. driving while under the influence); c) legal problems; and d) continued use of the substance despite persistent or recurrent social or interpersonal problems as a consequence of intoxication. It should be noted that if an individual meets the criteria for both Substance Dependence and Substance abuse, a diagnosis of Substance Dependence will be given due to its greater pathological severity. Adolescents diagnosed with a Substance Use Disorder are also impacted because they are highly likely to show polydrug use. They tend to begin using gateway drugs such as alcohol and nicotine, but can then move on to using marijuana and other illegal drugs. Youth with Substance Abuse or Dependence can be functionally impaired in one or more of the following ways: poorer academic achievement, associate with deviant peer groups who endorse substance use, engage in

Final Exam Sections - 19 delinquent behaviours, and may have frequent negative interactions with caregivers. In addition, adolescent Substance Use Disorders are most commonly co-morbid with other externalizing disorders such as Attention Deficit/Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). Co-morbidity with Anxiety Disorders and Mood Disorders has also been found but the relationship is less clear. Diagnostic Challenges One of the major diagnostic challenges facing an Anxiety Disorder such as Social Phobia is the DSM IV-TR (APA, 2000) criteria doesnt actually reflect the developmental perspective regarding child psychopathology. Anxiety is a natural emotional response serving to alert someone of a threat, providing them with an opportunity to confront or flee the situation. The challenge lies in determining what responses are considered developmentally normal from pathological reactions. The intensity and duration of anxiety reactions under normal conditions have not been studied in comparison to pathological anxiety states. Increased exposure to anxiety-inducing situations is part of normal developmental progression towards independence that all children and adolescents go through in their lives. There is a lack of research to make these distinctions, often leaving this discrimination in the hands of individual psychologists. Psychologists must also adapt adult criteria, taking into account the childs demographic and developmental variables such as age, gender, socioeconomic status, cultural background and cognitive level. This results in wide variation among clinician diagnosis because their decisions can be influenced by differences in training, experience, theoretical orientation, and familiarity with normal development as well as psychopathology. Another major diagnostic challenge facing Anxiety Disorders like Social Phobia is the underutilization of mental health services by youth with internalizing disorders despite being just as

Final Exam Sections - 20 impaired as children with externalizing disorders. There is often a failure to recognize and intervene early in the development of these disorders because these children and adolescents often suffer in silence if others around them are not impacted directly. If the individual is diagnosed with a co-morbid externalizing disorder, it is likely the anxiety disorder will be overlooked and the treatment would focus on the externalizing issues. When looking at the diagnostic challenges associated with Substance Use Disorders, one of the most pressing issues is diagnosing adolescents using adult criteria. As a result, the pattern of symptoms identified in the DSM IV-TR (APA, 2000) may not truly reflect how adolescents experience this disorder because the criterion is based on adult research. There are several reasons why the current diagnostic criteria may be inadequate for adolescents. First, the developmental level of youth needs to be considered. They are less likely than adults to exhibit impairment in occupational and romantic functioning due to their life experiences. This impacts how the criteria is used in diagnosing adolescents. Second, research on adolescent alcohol abuse also found that adolescents are less likely than adults to experience aspects of physiological dependence such as tolerance and withdrawal or medical complications. Finally, youth more commonly experience alcohol dependence symptoms such as blackouts, reduced activity level, affective symptoms, risky sexual behaviour and craarvings. With this in mind, clearly modifications need to be made to the classification system to more accurately reflect the impairment suffered by youth diagnosed with Substance Use Disorders. Sociodemographic Factors Gender and Socioeconomic Status Like many other internalizing disorders, Social Phobia has a higher rate of girls exhibiting core symptoms, with almost twice as many girls diagnosed with Social Phobia. Girls report significantly more major life events, higher levels of self-consciousness, lower self-esteem, more

Final Exam Sections - 21 physical illness and symptoms, greater emotional reliance and more social support from friends. They also report to consistently have a greater number of fears and anxieties than boys. Girls with Social Phobia are more likely to drop out of high school while, in college, both males and females suffer in their academic attainment. They also tend to have longer dependency on their families for support, less job training, more struggles entering into the work force and place greater demands on social and welfare systems. When socioeconomic status (SES) is examined, the population diagnosed with Social Phobia is predominately from a middle to low middle SES. Like many other externalizing disorders, Substance Use Disorders have a higher rate of boys exhibiting core symptoms. Girls use fewer types of drugs and engage in substance use less often than males. In the younger grades, gender differences appear to be less prominent. This may reflect a developmental phenomenon (varying rates of development for each gender) or a cohort effect (less gender differences among more recent cohorts). Either way, boys and girls seem to use drugs for different reasons. Males report higher rates of social and mood enhancer motives for drinking than females. Younger females report higher motives for conformity and coping behaviours than males, although these gender differences have been found to reverse at older ages. Studies of tobacco use have found females tend to be motivated more by weight regulation and anxiety reduction than males. In the middle school years, lower parental educational attainment and SES were related to adolescent substance use. However, the effects of SES diminish by grade 12. This may reflect either a greater high school dropout rate for adolescents from a lower SES, or a developmental phenomenon whereby substance use may become more equal across SES levels by the end of adolescence. Comparison

Final Exam Sections - 22 When comparing Social Phobia and Substance Use Disorders in youth, some similarities can be observed between the two disorders such as both are most often diagnosed in adolescence and can severely impair the daily functioning of an individual. Also, both disorders are co-morbid with depression. In fact, adolescents diagnosed with both Social Phobia and Major Depressive Disorder have an elevated risk of suicide and alcohol dependency. Another similarity is that the DSM IV-TR (APA, 2000) doesnt reflect the developmental perspective required for child and adolescent psychopathology in both disorders. With Anxiety Disorders such as Social Phobia, the distinction between developmentally normal and pathological responses to anxiety has not been clearly documented. With Substance Use Disorders, some of the criteria use to diagnose the disorder doesnt account for the developmental differences between adolescents and adult (e.g. impairment on romantic relationships or occupational roles). As a result, some youth fall between the cracks of a diagnosis despite displaying maladaptive behaviours. Social phobia and Substance Use Disorders are also similar because both disorders have many symptoms that overlap among various subtypes within each disorder. For example, there are several common features among all Anxiety Disorders such as recurrent and persistent thoughts of excessive anxiety and worry. For Substance Use Disorders, symptomology criteria for diagnosis remain the same regardless of the substance used by the adolescent. Research has uncovered an interesting finding between the relationship of Anxiety Disorders and Substance Use Disorders. Social Phobia is the only form of Anxiety Disorders that is considered co-morbid with Substance Use Disorders. All other forms of Anxiety Disorders seem to have the opposite effect. This is not fully understood within the research, but it is suggested the presence of an Anxiety Disorder reduces the risk of adolescent substance use because these youth are less likely to be involved in peer groups that promote substance use. However, Social Phobia differs in early adolescence and is a direct pathway to the development of a Substance Use

Final Exam Sections - 23 Disorder by middle to late adolescence. It is believed that adolescents suffering from Social Phobia use substances, such as alcohol, as a way of coping with stressful social situations. After experiencing some emotional relief from anxiety while intoxicated, the youth may feel the need to engage in this behaviour again in other social situations, resulting in substance use issues. Despite many similarities, there are also numerous differences between Social Phobia and Substance Use Disorders. When diagnosing Social Phobia, core symptoms from the diagnostic criteria must be present for 6 months, while symptoms must be present for 12 months for a Substance Use Disorder diagnosis. Another difference regarding diagnosis between the two disorders is the clarity of core symptoms. Anxiety is a natural emotional response making the discrimination between normal and maladaptive reactions difficult to distinguish. However, the identification of Substance Abuse or Substance Dependence seems easier to identify due to clearer, more concrete descriptors and the requirement of using a substance also makes it easier to identify. Another difference between Social Phobia and Substance Use Disorders is the diagnosed adolescents involvement in their peer group. Individuals with Social Phobia have few friends and are hesitant to join groups of peers and extracurricular activities. They are usually shy, quiet and spend their free time either alone or with one specific friend. Adolescents with Social Phobia also tend to be delayed in age-appropriate social development such as dating and maintaining a job. This socialization pattern directly contradicts the social interactions experienced by youth with Substance Use Disorders. For these adolescents, belonging to a peer group is very important. They identify the most with their peers and are often supportive of continued substance use. When looking at gender and SES, both factors seem to differ between the two disorders. In Social Phobia, girls are twice as likely to be diagnosed with the disorder and also have a higher number of fears. However, boys have a higher rate of diagnosis for a Substance Use Disorder. In

Final Exam Sections - 24 addition, girls are also more likely to drop out of high school when diagnosed with a Social Phobia, while boys with a Substance Use Disorder have a higher school dropout rate. When looking at SES for both disorders, Social Phobia is more predominant in middle to low-middle SES, while Substance Use Disorders are more prevalent in low SES in younger grades. However SES effects in Substance Use Disorders even out in later years. Finally, adolescents with Social Phobia are most commonly co-morbid with other anxiety disorders (internalizing), while Substance Use Disorders are more likely co-morbid with ADHD, ODD and CD (externalizing disorders). This follows a pattern familiar with other disorders and reflects the society view regarding the role of gender and personality characteristics that are identified as both masculine and feminine. Summary When making a quick comparison between Social Phobia and Substance Use Disorders, it would be easy to generalize that the two disorders are very different with little, if anything, in common. However, upon closer examination, these disorders share some traits and even are comorbid. It is very interesting that Social Phobia is the only Anxiety Disorder to have this relationship with Substance Use Disorders, while all other Anxiety Disorders seem to have protective factors associated. However, the typical features of both disorders are significantly different. One of the most noticeable differences between Social Phobia and Substance Use Disorders is socialization with peers. For adolescents with Substance Use Disorders, peers are highly motivating and influential. However, Social Phobia sufferers are often isolated and lonely. Overall, this paper shed some light of the typical features of both Social Phobia and Substance Use Disorders, diagnostic challenges and the impacts gender and SES have in child psychopathology.

Final Exam Sections - 25 This information will positively guide my practice and influence the lives of students diagnosed with either one of these disorders.

References American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition: Text Revision. Washington, DC. Mash, E. J. & Barkley, R. A. (2003). Child psychopathology, 2nd edition. New York: Guilford Press

APSY 651 Take Home Final 2009 Grading Rubric

12-15/15 Exceptional response that incorporates contemporary research findings and theoretical understandings of

8-11/15 Average response that shows a good understanding of the topic; overall wellwritten, but may lack somewhat in either depth and/ or

4-7/15 Poor response that may have inaccuracies; weak understanding of topic; understatement of complexities of the

0-3/ 15 Very weak paper; many inconsistencies/ inaccuracies; poorly written and presented; reflects very poor

Final Exam Sections - 26 the topic; shows a great deal of both depth and breadth of understanding of the topic in a succinct, well-presented paper; includes information that demonstrates a practical understanding of the topic breadth of understanding; incorporation of some contemporary thinking on the topic; conclusions could have practical applications topic; writing style is uneven or weak/ poor clarity; no evidence of a broader understanding of the topic understanding of the topic and applications; may be incomplete

Rhonda: 14/ 15 Thank you for your interesting responses to the exam questions. Your first response is interesting and I appreciated your ability to compare ADHD with a wide range of other diagnoses in such a succinct mannerit was a big bite to take, but you pulled it off nicely (although perhaps eliminating 1-2 of the disorders you presented would have allowed for a bit more depthnot a major issue, though). The comparison between Substance Use and Social Anxeity in particular was interesting and you did a good job of identifying some of the key areas of overlap between the two disorders. Again, well-done!

Thanks, and I hope that you and your family have a relaxing and enjoyable holiday!

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