1. Outline – Lecture10 [Mar.25/03] Chapter 12: Health-Related Disorders
1. Sleep Disorders
Dyssomnias
Parasomnias
2. Elimination Disorders
Enuresis
Encopresis
3. Chronic Childhood Illness
Factors related to adjustment
Asthma, Diabetes, Cancer
Compliance with medical routines

2. Normal Sleep Patterns & Difficulties
Age
< 1 year
1 year
2 years
3-5 years
school age
adolescence
Sleep and Common Disturbances
16-17 hours/day
13 hours/day including naps
reluctance going to sleep; nightmares
difficulty going to sleep; night wakening; nightmares
balance between sleep
and wakefulness develops
difficulties going to or
staying asleep

3. 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 decreased ability to inhibit or control basic drives, impulses, and emotions
Sleep allows for “uncoupling” of neurobehavioral systems, in turn allowing for retuning of CNS components

4. Sleep Disorders (cont.)
Normal Sleep Stages
During sleep, brain activity cycles between REM and NREM sleep
Brain activity is highest during REM sleep, and relatively quiet, slow, and synchronized during NREM sleep
During REM sleep new information is sorted and stored into memory
Children spend a long time in deep slow-wave NREM sleep

5. Sleep Disorders (cont.)
Situational and Cultural Influences
Children who have regular bedtime routines, including falling asleep in their own cribs or beds, have fewer sleep problems as they mature
Cultural influences and family expectations influence children’s sleep patterns
In some Eastern and South American cultures it is expected that young children will spend the first few years sharing their mothers’ room and bed—these families do not report more sleep problems

6. Sleep Disorders: 2 major categories
1. Dyssomnias or Insomnias
- disorders of initiating and maintaining sleep
Related to neurophysiological development
Parental & environmental factors may play a role
-Protodyssomnia - difficulty getting to sleep
-Hypersomnia - sleeping too much
-Narcolepsy - sleep attacks
-Obstructive Sleep Apnea Syndrome - disorder where
breathing ceases during sleep for brief periods
-Circadian Rhythm Sleep Disorder - inability to fall
asleep at the customary bedtime and the inability to rise
at a reasonable time

7. 2. Parasomnias
-disorders associated with sleep, sleep stages, or partial
arousal. Behavioral or physiological events intrude upon
on-going sleep
Nightmares: occur between ages 3 and 6
severely affect 10 to 50% of all children
Sleep terrors: typically occur between ages 4 and 12
child usually awakens screaming and in distress.
experienced in anywhere from 1 to 4% of children
Sleepwalking:
Occurs in first 3 hours of sleep [during NREM sleep]
Persists for number of years then disappears
May be due to immaturity of CNS [social and psychological factors may also be involved]

8. Nightmares vs. Sleep Terrors
occur during REM sleep
mid- to late-night
subdued verbalizations
moderate physiological arousal
slight or no movements
easy to arouse and responsive to environment
frequently remembered
common
reluctant to return to sleep
Sleep Terrors
occur during non-REM sleep
first third of night
verbalizations usually present
intense physiological arousal (heart rate, sweating, etc.)
extreme motor activity
difficult to arouse and unresponsive to environment
limited or no memory
somewhat rare (1-4%)
usually rapid return to sleep

9. Sleep Disorders Treatment
Most sleep problems resolve themselves as the child matures
Behavioral interventions and establishing good sleep hygiene can help children with difficulty going to and staying asleep
Narcolepsy the only dyssomnia requiring drugs in addition to behavioral intervention
Chronotherapy (re-setting of biological clock) may be necessary for severe circadian rhythm sleep disorders

10. Elimination Disorders: Enuresis
the involuntary discharge of urine.
only a disorder after age 5
Prevalence:
at age 8: 7% - boys more than girls
at age 10: 2% of females, 3% of males
by adolescence: about 1% of males and <1% of females
Nocturnal: nightime bedwetting
Diurnal: daytime wetting

11. Enuresis Primary [continuous]: never demonstrated bladder control
Secondary [discontinuous]: relapse into incontinence
Causes:
Emotional disturbance
Problems with arousal
Bladder capacity
Inadequate learning & inappropriate reinforcement
Treatment
Most successful treatments are behavioral training methods using either operant conditioning or classical conditioning (especially the urine alarm)

12. Elimination Disorders: Encopresis
The passage of feces into inappropriate places after age 4.
Retentive: Retain feces in bowel - suffer from overflow incontinence
Nonretentive: Stools passed into clothing or other inappropriate places- more intentional; often related to ODD or conduct disorder.
Prevalence:
affects 1.5% to 3% of children
frequency decreases with age
more common in boys than girls

13. Encopresis Primary: never demonstrated bowel control
Secondary: problem preceded by period of bowel control
Causes:
physiological-neurological mechanisms
Disruptions in mother-child relationship
Faulty toilet training
Treatment:
Combination medical & behavioural

14. Chronic Childhood Illness
A chronic illness is one that persists for more than 3 months or requires hospitalization for more than 1 month
Affects 10%-20% of children (about 1/3 have moderate to severe conditions)
Chronic illness does not necessarily lead to poor adjustment but illness and related life experiences place child at increased risk for such difficulties.
If medical condition accompanied by significant adjustment or behavior problems child may be diagnosed with an Adjustment Disorder

15. Chronic Childhood Illness (cont.)
Figure 12.1
Percentages of children with a psychiatric disorder among three groups: with chronic illness and disability, with illness and no disability, and physically healthy. (Data from Cadman et al., 1987)

16. Factors Related to Adjustment
[The Transactional stress and coping model]
Characteristics of the youngster
age, gender, intellectual ability, self- concept, coping strategies
Disease factors
severity, prognosis, degree of impairment
Environmental factors
family functioning and adjustment, degree of support and cohesion among members, etc.

17. Chronic Childhood Illness
increased risk for secondary psychological adjustment problems (often internalizing problems)
Most children adapt successfully to their illness
may result in PTSD in family members, as well as marital distress - most families adapt favorably
healthy parental adjustment related to healthy child adjustment
children with severe, disruptive illnesses suffer most in terms of social adjustment
children with chronic illness may demonstrate academic problems- primary effects vs secondary effects

18. Children's Experience & Understanding of Illness
Infancy: Neonates feel pain. Memory of painful experiences emerges after 6 months.
Toddlers: understand illness egocentrically; may assume responsibility for illness
Preschool: thinking becomes more differentiated [child realizes that certain familiar painful experiences are not due to badness]
Middle childhood: Thinking is accurate but concrete. Prevention is difficult to grasp.
Adolescents: cognitively capable of abstract adultlike definitions of illness but concepts are still predominantly concrete

19. Chronic Childhood Illnesses
Asthma
most common chronic illness in childhood
disorder of respiratory system
air passages are narrowed and air exchange impaired. Results in intermittent episodes of wheezing and shortness of breath called dyspnea.
Severe attacks known as status asthmaticus. Can be life threatening.

20. Chronic Childhood Illnesses
Diabetes Mellitus
A lifelong metabolic disorder in which the body is unable to metabolize carbohydrates as a result of inadequate pancreatic release of insulin
A progressive disease, with serious complications occurring in young adulthood and beyond (life expectancy 1/3 less than normal)
Requires daily treatments, including blood glucose monitoring, dietary restraints, insulin injections

21. Childhood Chronic Illnesses
Childhood Cancer
in comparison to adults, onset in children is more sudden and disease is often at a more advanced stage when first diagnosed
most common form is acute lymphoblastic leukemia
survival rates are better than in the past, although long term consequences may still pose risks
requires intensive medical treatment, especially during the first 2-3 years
prospect of death is an issue: understanding of death changes with age of child

22. Intervention Facilitating Medical Treatment
Managing Pain and Distress
Dealing with hospital experience
Psychosocial interventions can help children and their families to reduce and manage stress, enhance problem-solving skills, learn child-rearing practices, and become empowered
Families must be kept involved in intervention efforts

23. Compliance with Medical Routines
only 50% for the pediatric population
Factors related to noncompliance:
Aversiveness of medical procedures
Complexity of regimen
Chronicity of illness
General factors
To increase compliance:
verbal & written instructions, visual cues or reminders
multicomponent intervention programs [intensive education, self-monitoring, reinforcement procedures]