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Introducción Blind spots

• It is not common knowledge for example that in 1855 a French physician Maxime
Durand-Fardel supplied data on suicide in French children. He concluded that from the
period 1836 to 1844, 132 children in France had committed suicide in relation to
maltreatment. Two years later Ambrose Tardieu (1857; in Labb´e, 2005), a professor in
legal medicine in Paris, published a monograph about sexual abuse, followed three years
later by an article containing detailed data about 32 cases of child maltreatment (Tardieu,
1860; see also Roche, Fortin, Labb´e, Brown, & Chadwick, 2005). At the time, however,
Durand-Fardel and Tardieu did not succeed in bringing the miserable circumstances in
which so many children grew up to the notice of physicians. It was generally accepted
that children did not have rights, and that parents could determine how they punished
their children (Labb´e, 2005). Only thanks to the introduction of X-rays in diagnostic
procedures could Kempe and his colleagues, a century later, be successful in bringing
child maltreatment to the attention of professionals (Kempe, Silverman, Steele,
Droegemueller, & Silver, 1962).
• Sobremedicación.
• Garmezy and Rutter (1985) no se necesita un gran trauma para presentar psicopatología.
Historia: Antes del siglo XIX
• The first set of writings that we could locate where mention was made of
anxiety in children was in Hippocrates’ (460–370 BC) Aphorismes. In his
Aphorismes, Hippocrates reported fears as being among the illnesses of
newborns and infants, as well as aphthae, vomiting, and night fears.
• It was not until theMiddle Ages that anxiety in children was again the focus
of attention. Numerous “books of nurture” for parents and children remain
from the Middle Ages.
• Wardle (1991) reported that on the basis of such “books of nurture,” he
was able to isolate descriptions of 108 child behavioral and emotional
problems, including timidity, school refusal, and anxiety.
• DeMause (1974) and Shahar (1990) ejemplos del uso de temibles criaturas
enmascaradas o dibujos como técnicas de crianza de los niños durante este
tiempo.
• In terms of care, in the Middle Ages the care of children with disorders was
mainly in the hands of the Church. But also doctors were involved in
treating illness in children and adolescents: there are numerous sources in
Middle Ages literature, which could be regarded as the “first pediatric
publications,” such as
• The Boke of Children by the father of English pediatrics, Thomas Phaer
(1545). In these publications sleep disorders, nightmares, enuresis,
hysteria, and melancholia were treated (see reviews by Ruhr¨ah [1925] and
Demaitre [1977]).
• One of the few publications in which “fear” was addressed was the treatise
on stammering by the Italian doctor Hieronymus Mercurialis (1583) in De
morbis puerorum.
• The Dutchman JohannWeyer (1515–1588), the father of modern psychiatry
(Stone, 1973), and one of the first authors in child psychiatry (e.g., Wier, 1563)
• He illustrated that what was considered as work of the devil was in fact illness or
factitious disorder.
• the Englishman Robert Burton, in his famous dissertation on melancholy (in that
time referring to psychiatric illness in general), named “the power of Divels” as
one of the causes of melancholy (Burton, 1621).
• Specifically, Hippocratic explanations of psychiatric disorders in terms of
disturbances of humoral equilibrium made way to explanations wherein the
nervous system was at the center. Of particular note are the ideas of Franz Joseph
Gall (1758–1828). This German scholar studied in Vienna, and later in Paris, the
localization of psychic functions in brains and skulls. Gall also was interested in
the brains and skulls of psychiatric patients. His most well-known pupil was
Johann Spurzheim (1776–1832) who published a great deal about his
phrenological investigations of psychiatric disorders.
• At the same time psychological explanations for mental illness were
gaining ground.
• In this context, much significance was attached to the passions,
because passions – on the authority of the French doctor and
philosopher Pierre Cabanis (1757–1808) in his Rapports du physique
et du moral de l’homme (1802) – could have consequences in the
physiological domain. Accordingly, the repertory of treatment
modalities, in which bleeding still had an important position, was
extended to traitement moral (moral treatment), a predecessor of
psychotherapy. This initiative was especially stimulated by the French
psychiatrist Philippe Pinel (1745–1826). It is said that he released the
insane in the Bicˆetre from their chains in 1795.
• Another milestone around 1800 was the publication of a book
wherein Jean Itard (1775–1838) gave an account of his endeavors to
educate an enfant sauvage (feral child) (Itard,1801). This description
contributed to the identification of mentally handicapped children
apart from psychiatrically disordered children and to the
development of special facilities for mentally handicapped children in
the nineteenth century.
Historia: La primera mitad del siglo XIX
• 1800 the first descriptions were published of children with “moral insanity,”
where “moral” may usually be interpreted as “psychic.” Most case studies
appeared in books on general psychiatry. Alexander Crichton (1798)
published in his An Inquiry into the Nature and Origin of Mental
Derangement.
• Haslam in his Observations on Madness and Melancholy (1798; we
unfortunately only got hold of the second edition in 1809).
• Pinel (1801) in Trait´e m´edico-philosophique sur l’ali´enation mentale, ou
la manie.
• Perfect (1809) in Annals of Insanity.
• Adams (1814) showed a remarkable appreciation of the nuances involved.
“Madness,” he claimed, “as well as gout, is never hereditary, but in
susceptibility”
• Adam´s:
• Pero cuando la susceptibilidad no es más que una predisposición, que requiere el
funcionamiento de alguna causa externa para producir la enfermedad, hay
muchas razones para esperar, que la acción de la enfermedad puede ser
disminuida en su mayor parte, si no evitada por completo.
• Esquirol (1838), similarly, regarded heritability as the most general cause to
mental illness. the disease could nevertheless be transferred in another way,
from mother to child; that is, mothers who experienced strong emotions during
pregnancy had children who at the slightest cause could become insane.
• On the treatment the child receives from his parents during the infantile stage of
his life, will, perhaps, depend much of the misery or happiness he may experience,
not only in, his passage through this, but through the other stages of his
existence. (Parkinson, 1807, p. 468)
• Jarvis 1852. Another “mental cause” of mental disease in children
mentioned in the literature of these days was education: the view that
schooling – if begun too early or if too intensive – could be harmful to
mental health was popular in the nineteenth century.
• There are more and more of those whose love of knowledge, whose sense
of duty, whose desire of
• gratifying friends, and whose ambition, impel them to make their utmost
exertions, to become
• good scholars. Thus they task their minds unduly, and sometimes exhaust
their cerebral energies
• and leave their brains a prey to other causes which derange them
afterwards.
• Prevalencia
• The important role that Esquirol (1838) ascribed to the passions in
psychiatric problems
• is clear in the following statement: “One of the moral causes pointed
out by Pinel, and
• which is frequently met with in practice, is the conflict which arises
between the principles
• of religion, morality, education and the passions” (p. 47). Internal
conflict as a cause of
• mental illness had made its debut!
• Curso
• In the second edition of his Mental Pathology
• and Therapeutics Griesinger (1861), on the other hand, took a prospective approach:
• “Also after recovery such patients aremuch disposed to relapse; their mental health
continues
• in danger during the whole of their lives, or they occasionally become, without being
• actually insane, owing to an unfavourable change in their whole character, useless for the
• world” (p. 144). Commenting on the influence of mental disorders on the psychological
• development of the child in general, Griesinger (1861) claimed: “It is a general
characteristic
• of the mental disorders of childhood that they limit further mental development”
Historia: La segunda mitad del siglo XIX
• James Crichton-Browne, published a review of the state
• of the art in child and adolescent psychiatry at that moment. The British
doctor Charles
• West, regarded as the founder of modern pediatrics, contributed to child
and adolescent
• psychiatry. It is likely that both Crichton-Browne (Wardle, 1991) and West
were a source
• of inspiration for Maudsley, who, in 1867, published The Physiology and
Pathology of the
• Mind. This handbook contained a separate chapter on child and adolescent
psychiatry.
The developmental epidemiology of
anxiety disorders: phenomenology,
prevalence, and comorbidity.
Prevalencia: Preescolares
• Most of the research on anxiety and fear in young children has been
conducted from the perspective of temperament and normal
development, not psychopathology.
Prevalencia: Preescolares
• Between 7 and 12 months, most infants develop a fear of strangers and express
distress when separated from their primary caregivers. These fears peak between
9 and 18 months of age and decrease for most children by age 21/2
(Warren&Sroufe, 2004).
• About 15% of young children display “behavioral inhibition”: compared with
other children, they show more intense and persistent fear, shyness, and social
withdrawal in response to unfamiliar people, situations, or objects (Biederman et
al., 1990; Hirshfeld et al., 1992; Kagan & Snidman, 1991).
• Behaviorally inhibited young children display characteristic patterns of physiology
such as high heart rate, low heart rate variability, high baseline morning cortisol,
and elevated startle responses (Kagan, Reznick, & Snidman, 1987) and are more
likely to develop an anxiety disorder later in childhood or adolescence or to have
first-degree relatives with anxiety disorders (Biederman et al., 1993; Hirshfeld et
al., 1992; Kagan & Snidman, 1999
Clinimetría
• The Preschool Age Psychiatric Assessment (PAPA) (Angold et al., 2007;
Egger, Ascher, & Angold, 1999) was developed for use with parents of
children aged 2 through 5 years old.
• The Dominic (Murphy, Cantwell, Jordan, Lee, Cooley-Quille, & Lahey,
2000; Valla, Bergeron, & Smolla, 2000) is a pictorial interview
developed for children aged 6 through 11, and their parents.
• Development and Well-Being Assessment (DAWBA), an interview for
children and parents that is now widely used around the world, is
used with parents of children as young as 5 (Meltzer, Gatward,
Goodman, & Ford, 1999).
Prevalencia
• The median estimate for any anxiety disorder
in young children was 9.4%, with a range from
6.1% to 14.8%.
Prevalencia
• The median estimate for any anxiety disorder in
young children was 9.4%, with a range from 6.1%
to 14.8%.
• From our meta-analysis, the mean estimate for
any anxiety disorder is 12.3% (SE 5.4%); the 95%
credible range (roughly comparable to a 95%
confidence interval) is from 7.1% to 28.2%. The
most common anxiety disorder is specific phobia
(mean 6.7%, SE 3.6%), but as Figure 3.1 shows the
range is very wide, especially above the mean.
This diversity is because a few studies had very
high rates, probably because they did not impose
any impairment requirement before making the
diagnosis.
Prevalencia: 6-12 años
• Separation anxiety was the next
most prevalent anxiety disorder in
this age range (3.9%, SE 1.5%),
followed by social phobia (2.2%, SE
2.2%), and generalized anxiety
disorder (1.7%, SE 1.2%). There
were too few studies including
panic disorder to make a reliable
estimate.
Prevalencia: 13-18 años.
• the mean estimates are similar: any
anxiety disorder 11.0% (SE 0.5%),
specific phobia 6.7% (SE 1.6%),
social phobia 5.0% (SE 1.3%), SAD
2.3% (SE 0.9%), GAD 1.9% (SE
0.5%), andpanic disorder 1.1% (SE
0.3%).
Prevalencia
• Including all the data sets, with the addition of those that did not
permit age-specific estimates, did not change the picturemuch: any
anxiety disorder 10.2% (SE 0.5%), specific phobia 5.4% (SE 0.8%),
social phobia 3.6% (SE 0.7%), SAD 2.6% (SE 0.5%), panic disorder 0.8%
(SE 0.2%).
Prevalencia: Grupo de Edad
• the mean (and median) age at onset of any anxiety disorder
• by age 21 was 8 years, with 50% of cases falling between 6 and 12 years of
age. The earliest
• to begin was SAD, with a median age of 6 (mean 6.5), while panic disorders
rarely began
• before mid-adolescence. It is important to note that the range is very wide
for some anxiety
• disorders, especially GAD. It is also worth noting that in every diagnosis
except SAD, new
• cases were still being reported at the latest interview (age 21); the latest
case of separation
• anxiety disorder occurred at age 15.
Prevalencia: Sexo
• Lewinsohn identified a female preponderance in anxiety disorders that
emerged by age 6
• (Lewinsohn, Lewinsohn et al., 1998). In the GSMS (unpublished data), the
only anxiety
• disorder to be more common in pre-adolescent girls was separation
anxiety. In adolescence
• the difference was significant only for social phobia and GAD. This
difference continued
• into early adulthood, when young women also had significantly more cases
of panic
• disorder.
The “normal” development of fear
• The most widely used is the Fear Survey Schedule for Children (FSSC: Scherer &
• Nakamura, 1968) and in particular its revision, the FSSC-R (Ollendick, 1983). The FSSCR
• is a standardized 80-item measure, which asks children to rate how much fear they
• experience in response to a wide range of specific stimuli and situations, using a
threepoint
• response scale (“none,” “some,” or “a lot”).
• FSSC-R contains five factors: fear
• of danger and death (e.g., “Being hit by a car or truck”), fear of failure and criticism (e.g.,
• “Looking foolish”), fear of the unknown (e.g., “Going to bed in the dark”), fear of small
• animals (e.g., “Snakes”), and medical fears (e.g., “Getting an injection from the doctor”)
• (see Ollendick, 1983)
• Research has shown that normal anxiety phenomena in youths follow a predictable
developmental pattern.
• Jersild and Holmes (1935) who, based on parent report, concluded that between birth
and 6 years reports of fears of noise, pain, falling, and strange events declined; whereas
reports of fears of imaginary creatures, physical harm, and nightmares increased.
• Bauer (1976) found, based on child report, that 74% of the 4–6-year-olds, 53% of the 6–
8-year-olds, but only 5% of the 10–12-year-olds reported fear of ghosts and monsters. In
contrast, only 11% of the 4–6-year-olds, but 53% of the 6–8-year-olds and 55% of the
10–12-year-olds reported fear of bodily injury and physical danger.
• Muris,Merckelbach, Gadet, andMoulaert (2000) investigated the prevalence of fears,
worries, and scary dreams among 4–12-year-old children. Fears and scary dreams were
common among 4–6-yearolds, became even more prevalent in 7–9-year-olds, and then
decreased in frequency in 10–12-year-olds.Worry showed the opposite developmental
pattern: it was more prevalent in older children (i.e., 7–12-year-olds) than in younger
children.
• byWestenberg, Drewes, Goedhart, Siebelink, and Treffers (2004)
• also performed a developmental analysis of fears in 8–18-year-old
youths. Based on the
• observation that childhood fears can be divided in two broad
categories of physical harm
• and social problems, these researchers focused their analysis on the
developmental pattern
• of fears concerning physical danger and fears concerning social
evaluation.
Miedo normales
• Una posible explicación para el patrón de desarrollo en el miedo normal de los niños y la ansiedad es que las presiones evolutivas
han seleccionado un sistema de miedo que naturalmente se enfoca en ciertas amenazas ambientales a edades en las que estas
amenazas hubieran sido pertinentes para nuestros antepasados pretecnológicos.
• EVOLUCIÓN
• La evolución debería haber sido seleccionada por miedo y evitación de todas las cosas potencialmente peligrosas porque a esta
edad los niños están indefensos y este miedo innato mantendrá a los bebés a una distancia protectora de sus padres (4 to 8 years)
they will begin to explore their environment alone. At this age, encounters with predators are more likely to be fatal than for
adolescents and adults because, despite their new autonomy, children are still small and relatively powerless against an attack.
• Como tal, será extremadamente importante que aprendan sobre la amenaza de manera eficiente a esta edad para evitar
encuentros potencialmente catastróficos con los depredadores. La evolución debería, por lo tanto, seleccionar un sistema que
permita un aprendizaje rápido sobre la amenaza de los animales.
• As children move towards the teenage years they become physically stronger and more cognitively developed and are better able
to defend themselves or outwit predators. Natural wariness of predators should therefore wane. However, during the teenage
years children’s social position within the group becomes more vital: assuming a prominent position in the hierarchy could mean
the difference between survival or not. Again, therefore, evolution might select for a system that shifts the focus of threat into the
social world. All in all, it can be argued that normative fears seem to mirror plausible evolutionary concerns across children’s
development.
Social anxiety disorder: a normal fear
gone awry?
• Given the substantive and developmental parallels between normal and
• deviant anxiety it has been suggested that an anxiety disorder is a normal fear
development
• gone awry (see Muris & Field, Chapter 4 this volume; Westenberg, Siebelink, &
Treffers,
• 2001).
• Social anxiety may however be the exception to this rule.Contrary to thewell-
established
• link between specific phobia and childhood fears of animals, accidents, and
natural disasters
• there is little evidence to support the link between social anxiety disorder and
non-clinical
• social anxiety or social fears
• COGNITIVA
• Another explanation for the developmental pattern of childhood fear and anxiety is concerned
with the progress in children’s cognitive capacities. The basic idea is that fear and anxiety
originate from threat, and threat has to be conceptualized. Conceptualization, in turn, critically
depends on cognitive abilities (Vasey, 1993). Thus, at a very young age, fear and anxiety are
primarily directed at immediate, concrete threats (loud noises, loss of physical support). As
cognitive abilities reach a certain maturational stage, fear and anxiety become more
sophisticated. For example, at about 9 months, children learn to differentiate between familiar
and unfamiliar faces, and consequently separation anxiety and fear of strangers become manifest.
Following this, fears of imaginary creatures occur, and it is believed that these are closely linked
to the magical thinking of toddlers (Bauer, 1976). Fears of small animals and unknown stimuli in
the environment also develop during this phase, and are believed to be functionally related to the
increased mobility of children and their exploration and awareness of the external world. From 7
years onwards, children are increasingly able to infer physical cause–effect relationships and to
anticipate potential negative consequences. These cognitive changes are thought to broaden the
range of fear-provoking stimuli and enhance the more cognitive features of anxiety (e.g., worry).
Revisar articulo
• Westenberg et al. (2004) also
• examined whether developmental patterns in fears were predicted by youths’ level of
• cognitive maturation. As discussed earlier, the researchers found that children’s fears of
• physical danger decreased with age, whereas fears concerning social evaluation increased
• as children got older.Most importantly, however, the results indicated that the age effect in
• social–evaluative fears was fully explained by developmental trends in cognitive maturity.
• This led the authors to the conclusion that social fear and anxiety, which frequently arise
• during adolescence, are a corollary of cognitive development.

• It seems plausible that cognition is involved in developmental issues such as


• biological regulation in infants, magical thinking in toddlers, school adjustment in middle
• childhood, and formation of friendship during puberty, which according to some
• authors also determine the content of youths’ fear and anxiety (Warren & Sroufe, 2004).

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