Chapter 14

Psychology and Children’s Health

Eating Disorders

• Anorexia Nervosa• Bulimia• Obesity

4 characteristics often observed in victims of anorexia nervosa

• Most often between 14 and 18 years old• Primarily female• Often have perfectionist tendencies• Face a real risk of death

Social History of Anorexia Nervosa

• 1920s, “flapper” styles - eating disorders increased

• increasing prevalence of restrictive eating disorders in the 20th century, in the richer, more industrialized countries with thriving fashion industries

• True anorexia nervosa extremely rare in economically deprived groups and during wars and famines

Personality Traits Associated with Anorexia Nervosa

• Perfectionist tendencies• Excessive self-criticism, guilt, depression• Driven by need to be thin • Only a few had history of being overweight• Can run in families

The Course of Anorexia Nervosa

• Most describe experiences that they believe prompted or precipitated their unusual eating behavior

• onset usually quite sudden• Despite even strong objections from others,

anorexics deny that they are thin and continue behavior

• True anorexic pursues the destructive routine until physically unable to go on

Etiology of Anorexia Nervosa

• Why do seemingly trivial occurrences trigger their anorexia?

• Despite much study, the etiology of anorexia nervosa remains unclear– genetic factors

– hormonal and endocrine problems

– obsessive-compulsive tendencies, depression,

– Neither genetic nor environmental influences can be ruled out

Treatment of Anorexia Nervosa

• correct the individual’s nutrition problem and achieve medical stabilization

• Restore a normal diet, which can be difficult if patients resist

• Treatment must address a variety of factors since the weight and nutrition problems may be symptoms of other persistent psychological difficulties

• Therapy approaches often include family counseling. Family therapy seems to have more lasting effects

Bulimia Nervosa

• Bulimia vs. Anorexia– Bulimia Nervosa: frequent episodes of

uncontrolled binge eating alternately purging. Can co-occur with Anorexia Nervosa

– With Bulimia, individuals usually maintain weight close to appropriate level; with anorexia individual greatly underweight

• With Bulimia individuals fluctuate between gaining and loosing weight

• With Anorexia, individuals suffer extreme, life-threatening, weight loss.

Etiology of Bulimia Nervosa

• Causes of bulimia are somewhat unclear at this time.

• Preoccupation with food and have a persistent urge to eat

• Those with bulimia seem to have more affective disturbance, particularly depression, than most people.

• Higher than normal level of substance abuse, and some report a history of sexual abuse.

• Similar to anorexia, bulimia probably stems in part from cultural and social pressures to be thin

Treatment of Bulimia Nervosa

• medical evaluation of the individual should be undertaken at the outset.

– may be ruptures in the gastric or esophageal areas due to vomiting

– metabolic complications from either the vomiting or the abuse of laxatives

– Serious dental complications include erosion of tooth enamel from highly acidic vomit

• Approaches to bulimia have included medication and various combinations of education, counseling, and behavior management

• Antidepressants are helpful in reducing binge eating, despite a substantial relapse rate when discontinued

• Various strategies are used in behavioral therapy approaches

• Training in self-monitoring

• Cognitive-behavioral therapies

– basic behavioral management

– interrupting the disordered eating and then examining connections between certain cognitions and eating

– self-monitoring training and management of self-reinforcement contingencies

– relapse prevention and the use of multiple interventions Obesity

Obesity

• Obese individuals have excess body fat and weigh approximately 30% more than is considered normal

• 5 – 10% of preschool children are obese• 27% of ages 6-11 are obese• 22% of teenagers• Prevalence especially among children has

increased substantially in last 15 years

Childhood Obesity

• Serious health risk because it usually precedes a lifelong battle with obesity

• Depression• Social maladjustment

Causes of Obesity

• Theories vary and often appear to be in conflict

• One view hereditary or constitutional condition

• Physiologically, there seem to be two types of obesity

– Hyperplastic obesity occurs when an individual has an abnormally high number of fat cells

– Hypertrophic obesity occurs when individuals are overweight primarily because of extremely enlarged fat cells.

• Biological or physiological explanations feature the inheritance of a tendency toward obesity or slimness

• Many view learned behavior as an important cause of obesity

• Research suggests that obesity in youngsters does predict adult obesity

• Being grossly overweight has psychological con-sequences as well as physical dangers

– negative physical self-perceptions

– score lower on general self-worth than non-obese peers.

Treatment of Obesity

• Solutions and treatments for being overweight that might seem uncomplicated on the surface, often fail in the context of chronic obesity

– behavioral therapies

– medical treatments

• Treatment must be approached in a systematic fashion

– multidisciplinary team (perhaps consisting of a physician, nutritionist, psychologist, and exercise therapist) is more effective

– The ability to monitor one’s own behavior is important

Pharmacological Treatments

• Drugs that suppress appetite often have a number of undesirable or intolerable side effects

– lost weight is rapidly regained once the medication is discontinued

– Amphetamine-based medications that suppress appetite, increase activity, and heighten mood have been popular in both over-the-counter and prescription forms

• The benefits may be short-lived

Surgical Interventions

• restrict stomach capacity, either by stapling procedures or by inserting balloon-type devices into the gastric cavity

– These approaches should be employed only in the most severe cases when other therapies have been unsuccessful

Behavioral interventions

• Multifaceted behavioral treatment successfully treated obese children

• Children only age group for whom weight-reduction programs of any type have produced lasting benefits

• Behavioral programs tend to focus on managing eating behavior rather than attempting to change personality

• Self-monitoring capacity

– Obese people frequently do not realize the unsuitability of the foods they consume and how quickly and often they eat

– Self-monitoring allows the person to become conscious of behaviors that contribute to undesirable eating, which can then be targeted for modification

Toileting Problems

• Encopresis: Abnormal or unacceptable patterns of fecal expulsion by children beyond the age of toilet training and lacking organic pathology

• Enuresis: Recurrent bed-wetting or wetting of clothing at least twice a week for 3 months, diagnosed in children over 5

Encopresis

• Retentive encopresis: an excessive retention of fecal material

• Non-retentive encopresis: uncontrolled expulsion of feces (incontinence) resulting in soiled clothing and bedding

• discontinuous, or secondary, encopresis• continuous, or primary, encopresis • Distinctions are very important in trying to

establish causation and devise treatment

Treatment of Encopresis

• medical• psychoanalytic• behavioral

Medical treatment

• emphasize direct physical control of fecal matter using enemas, laxatives, and stool softeners along with modified diet and sometimes pediatric counseling

• In some cases, medication employed to control bowel actions

• Most view encopresis as a combined physiological and behavioral problem

• Multimodal treatments may include behavioral shaping as well as the physical control techniques mentioned above

Enuresis

• DSM-IV-TR cites prevalence for 5 – 10% for children at 5 years of age, 3 – 5% by age 10 and a lingering 1% of 15 year olds

• Most clinicians view urinary incontinence after about 3 to 5 years of age as a problem

Functional Nocturnal Enuresis

• May happen during the day• Connection between sleep and urinary

incontinence• Considerable attention given to the

relationship between enuresis and sleep patterns

• Some literature relates sleep cycles and sleep abnormalities to enuresis

The Psychodynamic

• interprets enuresis as a symptom of an inner conflict

• Effectiveness of psychoanalytic treatment has been poorly documented, and there is little research evidence for a success rate

Medical explanations

• Include developmental or maturational lag, genetic influences, abnormalities of the urinary tract, and a deficit in cortical control

Treatment

• Medications have been used

– Fluvoxamine is one popular alternative

• Behavioral approaches focus on the environmental contingencies related to urination.

– Urine alarms viewed as treatment of choice when combined with other treatments

Sleep Disorders

• May occur in 30-45% of very young children

• Specific sleeping difficulties, such as insomnia, are reported by a similar proportion of adults

Normal Sleep Cycle

• 2 distinct states– REM sleep: period during which rapid eye

movements occur and an individual dreams

– NREM sleep: lacks rapid eye movements, made up of 4 distinguishable stages

• Stage 1 : transitional period between wakefulness and sleep

• Stages 2, 3, and 4: characterized by differences in amount and type of brain-wave activity, generally spoken of as increasing in “depth” of sleep

Parasomnias

• sleep disruptions associated with specific parts of the sleep cycle, stages of sleep, or sleep-wake shifts

• Activation of physiological systems at inappropriate times during the sleep-wake cycle”

• Relate to cognitive processes

Nightmares and Night Terrors

• Sleep disorders in the parasomnia category • For some children, sleep disturbances are

frequent, persistent, and intense, and are then considered serious enough to be considered disorders

• tend to happen at different times of night and during different sleep stages. from ordinary dreams

Differences between nightmares and night terrors

• Children experiencing night terrors typically sleep through the episode, even though their behavior is extremely agitated.

• Eyes are often wide open, as though they were staring at something in terror; they make grimaces and exhibit considerable physical movement, sometimes running about the room frantically; they may also shout and scream.

• In nightmares, Children’s movements and verbalization much more subdued, typically restricted to moaning and slight movements in bed

• Nightmares followed by a period during which the child is awake, recognizes people and surroundings, can provide a coherent account of what has transpired, and can remember the contents of the dream

• Night terrors followed by instant and peaceful sleep, lack of recognition of people and surroundings, and frequently, complete amnesia regarding both contents and occurrence

Causes of nightmares and night terrors

• Largely unknown at this time• Theories

– sexual impulses that are not understood by the individual or experiences in a previous life

– associated with a variety of other conditions such as bronchial asthma, milk intolerance, night-time feeding, and genetic disposition

– multiple causes appear to be

Sleep-Walking Disorder (Somnambulism)

• Somnambulism and night terrors have a number of common features; not unusual to find both problems in the same child

• Can create serious problems since children can place themselves in danger by walking in unsafe places such as balconies and stairways

• senses are not functioning in a manner that would protect them from falling or other types of accidents

• Most often attributed to some type of emotional stress

• Treatment has followed several approaches with varying degrees of success

Dyssomnias

• Sleep disorders in which the affected individual has significant and chronic difficulty related to the “amount, quality, or timing of sleep”

Primary Insomnia

• Involves a problem in falling asleep that has a duration of at least a month, causes substantial impairment in several areas of functioning, and is not related to substance effects or a general medical condition

• Seems to begin in the early adult years and is relatively rare during childhood or adolescence

Causes

• Anxiety or worrying is a significant contributor to insomnia

• Some evidence suggests that stress, anxiety, and panic attacks are more frequent among individuals with serious insomnia conditions

Treatments

• Medication widely employed, but with mixed results

• Non-pharmacological treatments have the advantage of avoiding harmful side effects and placing the patient in greater control

• Comprehensive behavioral treatment packages have had high success rates

Narcolepsy

• Disorder in which individuals encounter “sleep attacks” at times when they are trying to stay awake

– often thought of as excessive sleep, but should more correctly be viewed as inappropriate sleep

Cause of Narcolepsy

• Largely eluded researchers to date

– One factor that has been identified relates to disturbances of REM sleep

Treatment of Narcolepsy

• Primarily drug therapy• Non-pharmacological treatments, such as

behavior management and diet alteration, are only recently getting attention in the literature, and considerable research is needed to establish their effectiveness

Speech Disorders

• Delayed Speech• Phonological (articulation) disorders• Stuttering (fluency disorder)

Definitions

• Defective speech refers to speech behavior that is sufficiently deviant from normal or accepted speaking patterns that it attracts attention and adversely affects communication for either the speaker or the listener

Delayed Speech

• Failure of speech to develop at the expected age – Some children with delayed speech develop

little or no expressive speech beyond vocalizations that are not interpretable as conventional language

– Other children with delayed speech can speak a little, but their proficiency is limited for their age and they mainly use nouns without qualifying or auxiliary words

Etiology of Speech Delays

• may stem from experience deprivation, • may be the result of sensory deprivation

from an anatomical defect such as a hearing loss

• neurological problems (e.g., cerebral palsy)• serious emotional disturbances such as

childhood schizophrenia and autism and less severe problems such as negativism

Negativism

• When children are developing speech, great pressure is being exerted on them by their parents to learn many other skills as well

• Demands exceed some children’s tolerance level, and they may be unable to perform as expected

• Certain children respond negatively to such a situation by refusing to perform

• If form of rebellion, the reward contingencies in the environment must be altered

• may also be necessary to alter behavior patterns that are only indirectly related to the speech delay

Experience Deprivation

• Environmental contingencies must exist in a configuration that will permit and promote children’s learning to speak

• Some households that do not promote language acquisition, and significantly delayed child speech may result

– child does not have much exposure to modeling of speech and perhaps receives little reinforcement for speaking and vocalizing

Other Circumstances

• A child with normal hearing capacity is born to deaf parents

• May also occur in homes where there is a great deal of verbalization and noise occurring in a very confused and unsystematic fashion

Treatment of Speech Delays

• Speech delay caused by experience deprivation can be treated by using fundamental principles of learning

Phonological Disorders

• Previously classified as articulation disorders

• Most frequently occurring category of all speech disorders according to DSM-IV-TR

Stuttering

• disorder of fluency and rhythm of speech with intermittent blocking, repetition, or prolongation of sounds, syllables, words, or phrases

• Despite the fact that stuttering is noticed, it is among the least prevalent of speech disorders

Etiology of Stuttering

• Stuttering may have a variety of causes

– an emotional or neurotic problem wherein stuttering is a behavioral manifestation of some emotional difficulty

– constitutional or neurological problem

– learning perspective

Treatment

• Psychotherapy met with limited success• Other treatment procedures have focused on

the rhythm process of speech, for example, • Treatment of stuttering increasingly

included behavioral therapy that attempts to teach the affected individual fluent speaking patterns Summary