Psikologi Anak

Pertemuan 12Health Related problems and substance use

Sleep Disorders The Regulatory Functions of Sleep• sleep is the main activity of the brain in the first years of life• sleep is essential for brain development and regulation• sleep deprivation impairs functioning of the prefrontal cortex, leading to

decreased concentration and diminished ability to inhibit or control basic drives, impulses, and emotions

• sleep produces an “uncoupling” of neurobehavioral systems, allowing for retuning of CNS components

Maturational Changessleep patterns, needs, and problems change over the course of maturation• infants and toddlers have more night-waking problems• preschoolers have more falling-asleep problems• younger school-aged children have more going-to-bed problems• adolescents have more difficulty going to or staying asleep, or having enough time

to sleep• adolescents have increased physiological need for sleep, however, they often get

less sleep than needed and are chronically sleep-deprived

Dyssomnias • Disorders of initiating or

maintaining sleep, characterized by difficulty getting enough sleep, not sleeping when one wants to, not feeling refreshed from sleep

• Most of these sleep problems resolve themselves as the child matures

• Quite common in childhood, with the exception of narcolepsy

Parasomnias

• Disorders in which behavioral or physiological events intrude upon ongoing sleep

• 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• behavioral interventions and establishing good sleep

hygiene can help children with difficulty going to and staying asleep

• behavioral interventions for circadian rhythm disorders can be effective when adolescent and family are highly motivated

• treatment of nightmares consists of providing comfort at the time of occurrence and making efforts to reduce daytime stressors

• parents of children who sleepwalk should take precautions to avoid chances of child being injured; brief afternoon naps may be beneficial

Elimination Disorders: Enuresis• involuntary discharge of urine during day or night at least twice a week for

three months or accompanied by significant distress or impairment, in a child at least 5 years old

• nocturnal enuresis most common (about 13-33% of all 5-year olds) and affects boys more than girls

• diurnal enuresis more common in females; believed to be associated with social anxiety or preoccupation with a school event

• more common among less educated, lower SES, and institutionalized children

• may be primary, if never attained continence, or secondary, if control established and then lost (less common)

• causes include deficiency of antidiuretic hormone, genetic predisposition, and immature signaling mechanism

• most successful treatments are behavioral training methods using either operant conditioning or classical conditioning (especially the urine alarm)

Elimination disorders: Encopresis• the passage of feces into inappropriate places at least once per

month for 3 months in a child at least 4 years old• 2 DSM-IV subtypes: with or without constipation and overflow

incontinence (former more common)• occurs in 1.5%-3% of children; declines rapidly with age• 5-6 times more common in boys• like enuresis, categorized as primary or secondary• psychological problems likely result from, rather than cause it• causes include untreated constipation and abnormal defecation

dynamics• treatment includes the use of fiber, enemas, or laxatives to treat

the constipation, followed by behavioral and biofeedback interventions to establish healthy elimination patterns

Adolescent Substance Abuse Disorders (SUDs)

• SUDs in adolescence include substance dependence and substance abuse, resulting from self-administration of any substance that alters mood, perception, or functioning

• Can lead to psychological and physiological dependence• For a diagnosis of substance dependence, must 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

• 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

Adolescent Substance Abuse Disorders (SUDs)

Prevalence and Course• alcohol is the most prevalent substance used and abused by

adolescents; cigarettes are second most common• illicit substance use also common; typically marijuana is used, but

the use of other illicit drugs such as MDMA, opiates, cocaine, and crack is increasing

• 8% of adolescents aged 12-17 met criteria for substance abuse or dependence in 2001 survey

• rates peak around late adolescence and begin to decline during young adulthood

• concern greatest when high-risk behaviors begin well before adolescence, are ongoing, and occur among peer group with similar behaviors

• high comorbidity with ADHD and conduct problems

Adolescent Substance Abuse Disorders (SUDs)

Causes• personality characteristics such as increased sensation

seeking- a preference for novel, complex and ambiguous stimuli

• positive attitudes about substance abuse and having friends with similar attitudes, perceiving oneself to be physically older than same-age peers, and school connectedness

• 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

• association with deviant and substance using peers

Treatment and Prevention• half of patients for SUDs relapse within first three months, and only 20-

30% remain abstinent • 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 parent-child communication about substance use

Feeding and Eating Disorders

Feeding Disorders• Infant or child refuses, is unable or has

difficulty eating– Frequent illnesses– Failure to thrive

• Not the same as eating disorders– Anorexia, bulimia – more common in adolescence

and adulthood

Feeding DisordersTypes of Feeding disorders:• Adipsia - absence of thirst• Dysphagia - real or imagined difficulty swallowing• Food refusal• Inability to self-feed• Taking too long• Choking; gagging or vomiting when eating• Picky eating according to food type or texture

Prevalence and Causes:• Approx. 25%, most common in children with developmental disorders• Medical conditions• Children tube fed through illness• Prematurity – reflux• Food allergies• Behaviour disorders

Eating Disorders

• Anorexia Nervosa – refusal to maintain a minimally normal body weight, intense fear of weight gain, significant disturbance in perception of body size

• Bulimia Nervosa – binge eating and inappropriate compensatory methods to prevent weight gain, excessively influenced by body shape and weight

Risk FactorsSchool age

• Primary school children want to be thinner than they are (up to 45%)

• 37% try some form of weight loss and 6.9% score in pathological range on Eating Attitudes Test

• Food refusal, ritualistic behaviour, internalizing symptomatology (anxious, withdrawn, somatic complaints)

Adolescence• Female gender• Girls who feel negatively about

their bodies at puberty• Anxious attachment• Affective problems• Discomfort discussing problems

with parents• Maternal preoccupation with diet• Family history• Personality/temperament• Sexual abuse

EtiologyPsychoanalytic• Symbolic of unresolved unconscious conflict

– Difficult to test• Poor mother-child relationship

– Rejecting mothers produce self-hate in their daughters– Daughters hate their bodies (too fat)– Evidence not consistent – most dislike their body shape but do not have

rejecting parents

Behavioural approach• Food avoidance or overindulgence is reinforced• Attention, control over parents• A better explanation for maintenance than for cause• Most with An are not rebellious but obedient, conscientious and

sometimes excellent athletes, perfectionists

EtiologyCognitive Behavioural approach• Begin with conditioned food aversions• Pair eating with obesity• Become revolted by food• Food avoidance maintained by sense of control by restricting• Faulty attributions used to justify food avoidance (‘you can’t be too thin’)

Social Psychological Approach• Cultural standards of beauty• Ideal thin female figure• 1960’s, 1970’s increasingly thin ideal• Women who try to meet the thin ideal have no choice but to diet and

some cannot stop– Some evidence (models, dancers, athletes)

Major Precipitants of an Eating Disorder

• Physical maturation• Entry into high school• Loss• An illness associated with weight loss• Peer teasing• Dieting

Warning Signs

To distinguish ‘normal’ dieting from an eating disorder• Dieting associated with decreasing weight goals• Dieting associated with increasing criticism of

body• Dieting associated with social isolation• Dieting associated with purging• Dieting associated with amenorrhea

Treatment

• Multi-disciplinary team• Medical – adequate weight gain and return to

physical health• Nutritional – resumption of normal eating• Psychological – resolution of distorted cognitions,

body image problems, self esteem, comorbid disorders

• Family – individuation, family relationships, parent-child conflict issues