Chapter 14
Psychology and Children’s Health
Eating Disorders
• Anorexia Nervosa
• Bulimia
• Obesity
4 characteristics often observed in victims of
anorexia nervosa
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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
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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 selfreinforcement 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 nonobese 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 weightreduction 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