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Chapter 12

Child Psychology Chapter 12.docx

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Psychology 2042A/B
Scott Wier

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Child Psychology Chapter 12: Health-Related and Substance Use Disorders Introduction  Health-related disorders are different from other mental disorders largely because children’s adjustment problems are more directly connected to the impact of the physical illness History  During the medieval period, these early philosophies were overshadowed by the belief that mental and physical illnesses were caused by demonic possession, requiring a quick and gruesome dispatch of the afflicted person  Psychodynamic theory and the emerging discoverths of modern medicine often clashed during the early years o the 20 century, however, as debates over the relative importance of the mind-body dichotomy  As a result of these developments, an early distinction emerged between disorders caused by physical factors and those caused by emotional or psychological factors  Physical disorders that stem form, or are affected by, psychological and social factors were referred to as psychosomatic and later, psychophysiologcal, which meant that psychological factors affected somatic (physical) function  Some historians argue that prior to the mid 19 century, children’s highly unpredictable lifespan contributed to a diminished emotional investment in children among parents and society  By the turn of the 20 century, according to professional and public opinion, enuresis, like childhood masturbation, was a potential sign of emotional and behavioural disturbance  By the 1920’s, the Infant Care Bulletin, the official publication of the U,S. Children’s Bureau, reflected the harsh stance of society toward choldrens developmental problems  It advised parents to force their children to have a bowel movement on a strict, regular schedule, and to complete toilet training 8 months of age at the latest  Toilet training issues once again emerged during the rebellious 1960’s, when renowned pediatrician Benjamin Spock was blamed for many social problems in North America because his advice on toileting and early childhood discipline from the 1940’s on was considered too lenient  The society of Pediatric Psychology was established in 1968 to connect psychology and pediatrics, which established the Journal of Pediatrics  How children adapt to the many situational, developmental, and chronic stressors affecting their health and well being is a primary interest of pediatric health psychology Sleep Disorders  Problems such as resistance at bedtime, difficulty settling at bedtime, night waking, difficulty waking up, and fatigue are among the most common complaints or concerns expressed by parents of young children  Sleep is the primary activity of the brain during the early years of development  By age 5 or so, a more even balance emerges between sleep and wakefulness  Still, by the time they begin school, children have spent more time asleep than in social interactions, exploration of the environment, eating, or any other single waking activity  Apparently sleep serves a fundamental role in brain development and regulation  Explain why sleep disturbances can affect overall physical and mental health and well being, and why sleep disorders are important to abnormal child psychology  Sleep problems co-occur with many different disorders, including ADHD, depression, anxiety, conduct problems, and developmental disorders  Sleep problems commonly arise from particular stressors – we tend to think that sleep difficulties are secondary symptoms of a more primary problem  However, the relationship between sleep problems and psychological adjustment is bidirectional  Sleep problems may themselves cause emotional and behavioural problems among children and adolescents, and they can be caused directly by a psychological disorder  In some circumstances, sleep problems might result from some underlying factor that is common to both sleep problems and other disorders  Problems in the brains arousal and regulatory systems can cause increased anxiety  Stress-related events increase arousal and interfere with normal sleep patterns  Sleep disorders have considerable importance to abnormal child psychology because they mimic or worsen many of the symptoms of major disorders The Regulatory Functions of Sleep  Sleep, arousal, affect, and attention are all closely intertwined in a dynamic regulatory system  When the CNS must increase arousal in response to possible danger, the system must recover soon thereafter and restore the balance between sleep and arousal  The giddiness, silliness, and impulsive behaviours children and adults show if sleep-deprived signify impairment in the prefrontal cortex functions  The prefrontal cortex is an important executive control center in the brain – it’s in charge of processing emotional signals and making critical decisions fro response  The prefrontal cortex is uniquely situated in the brain where it can integrate thoughts with emotions  If a parent is sleep-deprived or otherwise impaired, the first functions affected are the more complex, demanding tasks that require integrating cognitive, emotional, and social input rapidly and accurately  Sleep problems usually self-correct within a day or two  The physiology of sleep also has a fascinating connection to developmental problems that occur during childhood, and it further underscores the crucial role of sleep in restoring balance  Specific stages of sleep are believed to produce an active uncoupling, or disconnection, of neurobehavioral systems  In effect, separate aspects of the CNS take a break from their constant duty  As children mature, regions of the brain rapididly differentiate and establish specific functions and patterns of interconnection within the CNS which requires considerable recalibration or retuning Maturational Changes  Our sleep patterns and needs change dramatically during the first few years of life, then gradually settle into a stable pattern as we reach adulthood  Newborns sleep about 16-17 hours each day, and 1 year olds sleep about 13 hours a day, including naps  Adolescents have an increased physiological need for sleep, but many get significantly less sleep than during early childhood  This results in many teens’ being chronically sleep-deprived, with daytime symptoms of fatigue, irritability, emotional liability, difficulty concentrating, and falling asleep in class Features of Sleep Disorders  Primary sleep disorders are presumed to be a result of abnormalities in the body’s ability to regulate sleepwake mechanisms and the timing of sleep, as opposed to sleep problems related to a medical disorder, a mental disorder, or the use of medications  The DSM divides primary sleep disorders into two major categories: o Dyssomnias: disorders initiating or maintaining sleep, characterized by difficulty getting enough sleep, not sleeping when you want to, not feeling refreshed from sleeping, and so forth o Parasomnias: sleep disorders in which behavioural or physiological events intrude on ongoing sleep  Whereas dyssomnias involve disruptions in the sleep process, parasomnias involve physiological or cognitive arousal at inappropriate times during the sleep-wake cycle, which can result in sleep-walking or in nightmares that jolt someone form sleep  Persons suffering from parasomnia sleep disorders often complain of unusual behaviours while asleep, rather than sleepiness or insomnia Dyssomnias  Fortunately, many sleep problems resolve themselves as the child matures, especially if parents are given basic information and guidance  For the most part, dyssomnias are common childhood afflictions, with the exception of narcolepsy, which is rare and primarily affects adolescents and adults  Breathing-related sleep disorders are somewhat less common and can affect children of various ages as a result of allergies, asthma, or swollen tonsils and adenoids  Although relatively common, dyssomnias can sometimes have a significant impact on children’s behaviour and emotional state, much like they impact adult behaviour Parasomnias  Parasomnias are somewhat common afflictions during early to mid- childhood  They include nightmares, sleep terrors, and sleepwalking  Nightmares are referred to as REM parasomnias because they occur during REM sleep, usually during the second half of the sleep period  Sleep terrors and sleepwalking, in contrast, are referred to as arousal parasomnias because they occur during deep sleep in the first third of the sleep cycle when the person is so soundly asleep that he or she is difficult to arouse and has no recall of the episode the next morning  Children typically grow out of parasomnias or recover from sleep disruption or sleep loss and do not develop chronic-condition that interferes with daily activities  DSM criteria for sleep disorders typically are not met in full by younger children because of the transitory nature of their sleep problems  DSM diagnostic criteria for all sleep-related disorders emphasize: 1. The presence of clinically significant distress or impairment in social, occupational, or other important areas of functioning 2. The requirement that the sleep disturbance cannot be better accounted for by another mental disorder, the direct physiological effects of a substance, or a general medical conditions  These considerations apply to all the disorders discussed in this chapter Treatment  Sleeping difficulties in infants and toddlers often subside on their own  If going to sleep or staying asleep becomes difficult, the goal of behavioural interventions is to teach parents to attend to the child’s need for comfort and reassurance, but to gradually withdraw more quickly from the child’s room after saying goodnight  Parents also can be taught to establish good sleep hygiene appropriate to their child’s developmental stage and the family’s cultural values  Once established, positive reinforcement method, can be used to reward the child for efforts to follow the bedtime routine  The goal of behavioural intervention is twofold: to eliminate the sleep deprivation and to restore a more normal sleep and wake routine  Treatment for some dyssomnias, prolonged treatment of child and adolescent parasomnias is usually not necessary, particularly if the episodes of sleep intrusion occur infrequently  If nightmares or sleep terrors are intense and persistent, daytime stresses at school, family conflicts, or emotional disturbance may be implicated  If sleepwalking is confirmed, parents must take precautions to reduce the chance of injury to a child who may fall or bump into objects Elimination Disorders  Thanks to a better understanding of the biological and psychological underpinnings of elimination disorders, attention has been directed away from the child’s personality or emotional trauma  Elimination problems can turn into distressing and chronic difficulties, and can affect participation in educational and social activities, camps, sleepovers, and so forth  Two elimination problems that occur during childhood and adolescence are enuresis, the involuntary discharge of urine during the day or night, and encopresis, the passage of feces into inappropriate places, such as clothing or the floor  These elimination problems can have strong implications on the development of self-competence and self-esteem  Most children eventually outgrow problems of enuresis or encopresis by age 10 or so  In most instances the problems can be alleviated through educating and retraining efforts involving both parents and children  Early referral and treatment can virtually eliminate long-term consequences Enuresis  Most of the time the child cannot control the discharge, but on occasion it may be intentional  Most children have bed-wetting accidents until age 5 or so, therefore DSM has narrowed the criteria to reflect the developmental nature of this disorder  The criteria stipulate that the problem be frequent r accompanied by significant distress or impairment in social, academic, or other important areas of functioning  The voiding of urine into bed or clothes must not be due exclusively to a general medical condition, or the result of a diuretic, which is a drug that reduces water retention  DSM distinguishes between three subtypes of enuresis o Nocturnal only – the most common o Diurinal only – passage of urine during waking hours, most common in females and uncommon after 9 o Noturnal and diurinal combined Prevalence and Course  Occurs in boys more often than girls  Declines with maturity  Prevalence of both forms of enuresis is higher among less educated, lower SES as well as institutionalized children, perhaps due to less structure in their daily routines and added environmental stressors  Primary enuresis never attained at least 6 months of continuous nighttime control  Secondary enuresis is less common and refers to children who have previously established urinary continence but then relapse  Teasing, name calling, and social stigmatization are common peer reactions to this unfortunate problem  Although enuresis is a physical condition, it is often accompanied by some degree of psychological distress  The impact of this distress often depends on three features related to the nature of the enuresis: 1. Limitations imposed on social activities, such as sleeping away from home 2. Effects on self-esteem, including the degree of social ostracism imposed by peers 3. Parental reactions such as anger, punishment, and rejection  Many children with enuresis are able to establish their self-esteem and peer relationships despite their occasional embarrassment or anxiety Causes and Treatment  Children who continue to need to urinate at might may have a deficiency during sleep of an important hormones known as antidiuretic hormone (ADH)  ADH helps concentrate urine during sleep hours and has therefore decreased volume  Children with enuresis do not show the usual increase in ADH during sleep  The reason with enuresis fail to wake up when they need to urinate can also be explained by developmental and biological factors  Older children and adolescents are able to sense a full bladder at night, which activates a nerve impulse from the bladder to the brain  Some children with primary enuresis, however, lack normal development of this signal processing in the brain  Primary enuresis appears to be inherited  The standard behavioural intervention, based on classical conditioning principles, is using an alarm that sounds at the first detection of urine  They are among the safest and most effective treatments  The one drawback to this method is the alarm’s unpopularity with other household members  If this ritual is carefully followed, the alarm will begin to wake the child directly within 4-6 weeks, and by 12 weeks he will likely master nighttime bladder control and no longer need the alarm  Another behavioral method, based on operant conditioning principles involves variations of dry-bed training  Children, like adults, wake up more easily when the day holds promise and excitement. Reward systems, capitalize on this anticipation  During a single office visit, parents are instructed in bladder retention control training by having their child drink more and more fluids during the day, and then delay urination for longer periods, hourly wakings for trips to the toilet, a cleanup routine for accidents, and positive reinforcement contingent on dry nights  This routine is practiced nightly for 1-2 weeks  In the mid-1980’s, desmopressin, a synthetic ADH, became available as a treatment for enuresis, and is a simple nasal spray administered before bedtime  Although desmopressin works very well while children are on the medicine, the difficulty comes in keeping them dry when they stop the medication  Psychological treatments for enuresis have been more effective overall than pharmacological treatments Encopresis  Encopresis refers to the passage of feces into inappropriate places, such as clothing or the floor  This act is usually involuntary, but may occasionally be done intentionally  The diagnostic criteria stipulate that this event must occur at least once per month for a least 3 months, and that the child must be 4 years old or older  Two subtypes of encopresis are described in DSM with or without constipation and overflow incontinence Prevalence and Course  This disorder is more common in boys and it decreases rapidly with age  Encopresis can be categorized as primary or secondary  Psychological problems, more likely result from, rather than initially cause, the encopresis  The degree of children’s impairment and associated psychological distress is partially a function of social ostracism by peers, as well as anger, punishment, and rejection on the part of caregivers Cause and Treatment  Overly aggressive or early toilet training, family disturbance and stress, and child psychopathology have all been thought to cuase encopresis at one time or another  However, encopresis is a physical disorder that can lead to, but seldom results from, psychological factors alone  The sooner it is diagnosed and treated, the less likely the child will suffer any lasting emotional scars or disruptions in social relationships  Understanding the etiology of encopresis leads to a discussion of toilet training where children first learn to control bowel movements  Children who develop this pattern of avoidance also have abnormal defecation dynamics  They contract rather than relax the external sphincter when they attempt to defecate  Anxiety about defecating in a particular place, or because their toileting experiences were stressful and harsh, can cause chronic constipation  Optimal treatment of encopresis involves both medical and behavioural interventions to help the child learn to empty the colon to allow it to return to normal size and function  To get the process moving fiber, enemas, laxatives, or lubricants may be given to disimpact the rectum  Then, to establish a better routine and healthy pattern of eliminating, behavioural methods are used in combination with laxatives or similar agents  Behavioural methods involve teaching a toilet-training procedure that encourages detection of and response to rectal distention cues, parental efforts to praise the child’s clean pants and toilet use, and regularly scheduled toilet times after meals  With a combination of laxatives and behavioural treatment, most children improve significantly within the first 2 weeks of treatment Chronic Illness  A chronic illness is one that persists longer than 3 months in a given year, or that requires a period of continuous hospitalization of more than 1 month  Children and adolescents whose health and functional ability is comprised by a chronic medical condition face numerous challenges to their development and adjustment  Like other developmental disorders, these conditions impact not only the child but peers and family members as well  The DSM addresses the mental health issues pertaining to health-related disorders in children and adults indiscriminately, relying mainly on two quite distinct categories: somatoform disorders and psychological factors affecting physical condition  Somatoform disorders are a group of related problems involving physical symptoms that resemble or suggest a medical condition, but lack organic or physiological evidence  Somatization, hypochondria, and pain disorders are examples of somatoform disorders  Diagnostic criteria involve a clustering of complaints with pain and gastrointestinal, sexual, and pseudoneurological symptoms that exist at any time during the course of the disturbance  These symptoms are not intentionally produced or feigned, and they are real enough to cause significant distress or impairment to the individual  A strong presumption of a psychological component to the symptom is
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