12 Health-Related and Substance Abuse Disorders
Chapter Outline:
I.
Sleep Disorders
A.
The Regulatory Functions of Sleep
1.
Sleep is the primary activity of the brain during the early years of
development; by about age 5, a more even balance emerges between sleep
and wakefulness
2.
Sleep serves a fundamental role in brain development and regulation
3.
Sleep disorders can cause other psychological problems or can result from
other disorders or conditions
4.
Transient sleep problems are normal and are usually alleviated by
reducing stress, ensuring safety, and providing reassurance and consistent
limits
5.
Sleep deprivation impairs the functioning of the prefrontal cortex, leading
to decreased concentration and diminished ability to inhibit or control
basic drives, impulses, and emotions
6.
Sleep produces an “uncoupling” of neurobehavioral systems, allowing for
retuning of the components of the central nervous system
B.
Maturational Changes
1.
Sleep patterns, needs, and problems change over the course of
maturation—infants and toddlers have more night-waking problems;
preschoolers, more falling asleep problems; younger school-age children,
more going-to-bed problems; and adolescents, more difficulty going to or
staying asleep or not having enough time to sleep
2.
Adolescents have increased physiological need for sleep; however, they
often get less sleep than needed and are chronically sleep-deprived
C.
Features of Sleep Disorders
1.
Two major categories: dyssomnias and parasomnias
2.
DSM-IV-TR criteria for sleep disorders not typically met in full by
younger children due to the transitory nature of sleep problems
3.
Diagnostic criteria emphasize the presence of clinically significant distress
or impairment in functioning and the requirement that the sleep
disturbance cannot be better accounted for by another disorder or
condition
4.
Dyssomnias
a.
Disorders of initiating or maintaining sleep, characterized by
difficulty getting enough sleep, not sleeping when one wants to,
not feeling refreshed from sleep
b.
Most of these sleep problems resolve themselves as the child
matures
c.
Quite common in childhood, with the exception of narcolepsy
5.
Parasomnias
a.
Disorders in which behavioral or physiological events intrude upon
ongoing sleep
b.
c.
D.
II.
Common afflictions of early to mid-childhood; children typically
grow out of them
Include nightmares (often called REM parasomnias), sleep terrors
and sleepwalking (often referred to as arousal parasomnias)
Treatment
1.
Behavioral interventions and establishing good sleep hygiene can help
children with difficulty going to sleep or staying asleep
2.
Behavioral interventions for circadian rhythm disorders can be effective
when adolescent and family are highly motivated
3.
Prolonged treatment of child and adult parasomnias is usually not
necessary
4.
Treatment of nightmares consists of providing comfort at the time of
occurrence and making efforts to reduce daytime stressors
5.
Parents of children who sleepwalk should take precautions to avoid
chances of child being injured; brief afternoon naps may be beneficial
Elimination Disorders
A.
Enuresis
1.
The involuntary discharge of urine during the day or night
2.
Because bed-wetting is quite common, diagnostic criteria stipulate that the
problem occur at least twice a week for three months or be accompanied
by significant distress or impairment, in a child at least 5 years of age (or
equivalent developmental level)
3.
Nocturnal enuresis, in which wetting occurs during sleep at night
(typically the first third of the night), is most common (about 13-33% of
all 5-year-olds) and affects boys more than girls
4.
Diurnal enuresis (in which wetting occurs during waking hours) is more
common in girls and is uncommon after age 9; it is believed to be due to
social anxiety or preoccupation with a school event
5.
Nocturnal and diurnal enuresis can exist in combination
6.
Prevalence of enuresis declines rapidly with maturity
7.
Higher prevalence among less educated, lower socioeconomic groups, and
institutionalized children
8.
Enuresis may be “primary,” if the child never attained continence (applies
to 85% of cases), or “secondary,” if established continence was lost
9.
Causes
a.
Nocturnal enuresis has been linked to a deficiency during sleep in
antidiuretic hormone, which helps concentrate urine during sleep
hours
b.
Primary enuresis may be associated with immature signaling
mechanisms, making it difficult to detect the need to urinate
c.
Family and twin studies suggest primary enuresis is inherited
10.
Treatments
a.
Behavioral training methods using either an alarm or reinforcement
contingencies are often very effective at teaching bladder control
b.
Dry-bed training based on operant conditioning principles
c.
B.
Encopresis
1.
The passage of feces into inappropriate places, such as clothing or the
floor
2.
Diagnostic criteria stipulate that it occur at least once per month for at
least 3 months, in a child at least 4 years of age (or equivalent
developmental level)
3.
Two DSM-IV-TR subtypes: with or without constipation and overflow
continence (the former is more common)
4.
Occurs in 1.5% to 3% of children, and is 5 to 6 times more common in
boys; frequency declines rapidly with age
5.
Like enuresis, it can be categorized as primary or secondary
6.
May be associated with significant psychological problems, which likely
result from, rather than cause, the encopresis
7.
Causes
a.
May be related to untreated constipation—child may try to avoid
bowel movements because they have been painful in the past,
which only serves to make the next time painful too, because
unpassed feces become large, hard, and dry. Furthermore, over
time, the stretched muscles and nerves give fewer and fewer
signals to the child about the need to have a bowel movement
b.
About 50% of cases are associated with abnormal “defecation
dynamics”, in which the child contracts rather than relaxes the
external sphincter
8.
III.
A synthetic antidiuretic in the form of a nasal spray can be
administered before bedtime; however, this treatment is less
effective than psychological treatments
Treatment
a.
Fiber, enemas, laxatives, or lubricants may be given to help relieve
constipation
b.
Behavioral methods involving teaching a toilet-training procedure
may be effective
c.
A combination of laxatives and behavioral treatment has shown
significant improvements within the first two weeks, and over 75%
maintain the improvement
Chronic Childhood Illness
A.
A chronic illness is one that persists longer than 3 months in a given year, or
requires a period of continuous hospitalization of more than 1 month
B.
DSM-IV-TR identifies two health-related categories:
1.
Somatoform disorders- a group of related problems involving physical
symptoms that resemble or suggest a medical condition but lack organic or
physiological evidence (includes somatization, hypochondriasis, and pain
disorders)
2.
Psychological factors affecting physical condition- disorders in which
psychological factors are presumed to cause or exacerbate a physical
condition; does not apply to most children with chronic health conditions
C.
D.
E.
F.
G.
If a medical condition is accompanied by significant adjustment or behavioral
problems, a child may be diagnosed with Adjustment Disorder
Normal Variations in Children’s Health
1.
Children experience pain in the same way as adults
2.
Children may use pain for secondary gains
3.
One of the most common ways for children to express their fears, dislikes,
and avoidance is through somatic complaints
4.
Girls show more symptoms of pain and anxiety than boys, a difference
which is likely due to socialization expectations, rather than physiological
differences
5.
Family influences can impact children’s expressions of pain and physical
symptoms (likely through social learning)
6.
Chronic illnesses and medical conditions constitute a major stressor that
challenges and absorbs both the child’s and the family’s available coping
resources
7.
Affect from 10% to 20% of the child population (about 1/3 have moderate
to severe conditions)
8.
Asthma is the most common chronic illness in childhood
9.
Social class and ethnicity do not influence who is affected by chronic
illness (with the exception of specific conditions that are genetically
determined by racial or ethnic decent, such as sickle-cell disease), but
there is a relationship between SES and survival rates
Diabetes Mellitus
1.
A lifelong metabolic disorder in which the body in unable to metabolize
carbohydrates as a result of inadequate pancreatic release of insulin
2.
Affects boys and girls equally
3.
A progressive disease, with the more chronic complications occurring in
young adulthood or beyond; life expectancy is 1/3 less than of the general
population
4.
Requires daily treatments to maintain metabolic control, such as blood
glucose monitoring, dietary restraints, insulin injections, and learning how
to balance energy demands with insulin needs
Childhood Cancer
1.
In comparison to adults, the onset of cancer in children is more sudden and
the disease is often at a more advanced stage when first diagnosed
2.
The most common form is acute lymphoblastic leukemia
3.
Requires intensive medical treatment, especially during the first 2-3 years
4.
Approximately 80% of pediatric cancer patients survive; 50% will have
serious physical or mental illness as adults and will require long-term care
Development and Course
1.
Children with chronic illness, especially those with physical disabilities,
have an increased risk of secondary psychological adjustment difficulties
(most often internalizing problems), although the incidence of DSM-IVTR type disorders among children with chronic illness is actually low
2.
Most children are able to adapt successfully to the course and
consequences of their illness
3.
IV.
Chronic illness may precipitate PTSD in family members, as well as
marital distress, although most families adapt favorably
4.
Factors associated with children’s situations- like family stress and
resources- may be more critical to their adaptation than the challenges
posed by the illness alone; healthy parental adjustment related to healthy
child adjustment
5.
Siblings of children with a chronic illness experience heightened social
and mental health problems
6.
Children with more severe, disruptive illnesses tend to suffer most in
terms of social adjustment
7.
Children with chronic illness may demonstrate academic problems, which
may be due to the primary effects of the illness or treatment, or the
secondary effects of the illness, such as fatigue, absenteeism, or
psychological stress
H.
How Children Adapt: A Biopsychosocial Model
1.
The transactional stress and coping model shows how children’s
adaptation to chronic illness is influenced by the nature of the illness as
well as personal and family resources
2.
Illness parameters include severity, prognosis, and functional status
3.
Personal characteristics, e.g., age, gender, ethnicity, SES, intellectual
ability, self-concept, coping abilities
4.
Family adaptation and functioning, including how parents manage daily
stress; whether parents use active, solution-focused coping strategies; the
degree of support and cohesion among family members; parent
perceptions of illness; and the availability of utilitarian and psychological
resources
I.
Intervention
1.
Child and family adaptation can be strengthen by psychosocial
interventions that reduce stress, enhance social problem-solving skills,
promote effective child-rearing methods, and empower families
2.
Families are kept in the forefront of children’s intervention needs, not the
background
3.
There are two main psychological approaches to helping children cope
with stressful medical procedures and chronic and recurrent pain:
providing information (e.g., verbal explanations and demonstrations) and
training in coping skills (e.g., deep breathing, attention distraction, muscle
relaxation, relaxing imagery, emotive imagery, and behavioral rehearsal)
Adolescent Substance Abuse Disorders
A.
Substance Use Disorders (SUDs)
1.
SUDs in adolescence include substance dependence and substance abuse,
resulting from self-administration of any substance that alters mood,
perception, or functioning
2.
Can lead to psychological and physiological dependence; to receive a
diagnosis of substance dependence, an adolescent has to show a
maladaptive pattern of substance use for at least 12 months, with three or
more clinical signs of distress such as tolerance or withdrawal
3.
B.
C.
D.
Criteria for substance abuse involves one or more harmful and repeated
negative consequences of substance abuse over the last 12 months; given
if individual does not meet criteria for dependence
Prevalence and Course
1.
Alcohol is the most prevalent substance used and abused by adolescents (4
out of 5 high school seniors have used alcohol); cigarettes are the second
most common (60% of high school seniors have smoked)
2.
Illicit substance use also common (over half of high school seniors have
used drugs other than alcohol or cigarettes); typically marijuana is used,
but the use of other illicit drugs such as MDMA, opiates, cocaine, and
crack is increasing
3.
8% of adolescents aged 12-17 met criteria for substance abuse or
dependence in 2001 survey
4.
Alcohol use before age 14 is a strong predictor of subsequent alcohol
abuse or dependence, especially if followed by rapid increase of alcohol
consumption
5.
Sex differences converging, due to increased substance use among girls
6.
Notable ethnic differences- substance use highest among Native
Americans boys and girls, lower among White, Hispanic/Latin and
African-American, and lowest among Asian-American adolescents
7.
Rates peak around late adolescence and begin to decline during young
adulthood
8.
Similar to conduct disorders, concern greatest when high-risk behaviors
begin well before adolescence, are ongoing, and occur among peer group
with similar behaviors
9.
Adolescents diagnosed with SUDs tend to use more than one drug at a
time, have problems related to poor academic achievement, higher rates of
academic failure, higher rates of delinquency, and more parental conflict;
heavy drinking in mid-teens may disturb ongoing neurodevelopmental
processes
10.
High comorbidity with ADHD and conduct problems
Causes
1.
Personality characteristics such as increased sensation seeking- a
preference for novel, complex and ambiguous stimuli
2.
Positive attitudes about substance abuse and having friends with similar
attitudes, perceiving oneself to be physically older than same-age peers,
and school connectedness
3.
Lack of parental involvement and parent-child affection, inconsistent
parenting and poor monitoring, negative parent-child and inter-parent
interactions, and low parental expectations for abstaining
4.
Association with deviant and substance using peers
Treatment and Prevention
1.
Half of patients with SUDs relapse within first three months, and only 2030% remain abstinent
2.
3.
4.
5.
6.
Family based approaches that seek to modify negative reactions between
family members, improve communication, and develop effective problem
solving skills to deal with areas of conflict
Multisystemic Therapy (MST) involves intensive intervention that targets
family, peer, school, and community systems
Adolescents with more severe levels of abuse and unstable living
conditions, or comorbid psychopathology require inpatient or residential
setting
Life skills training emphasizes building drug resistance skills, personal
and social competence, and altering cognitive expectancies around
substance abuse
Prevention efforts target social environment via community and school
norms, and include parent involvement and education to improve parentchild communication about substance use