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Chapter 12
Health-Related and
Substance Use Disorders
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
History
 Ancient Greek philosophers: pain and disease are caused by
an imbalance in the body’s basic elements (fire, air, water,
and earth)
 Medieval period: mental and physical illnesses result from
demonic possession
 19th century: Charcot and Freud studied the role of the mind
in physical symptoms (conversion hysteria)
 Mind-body dichotomy was subject of heated debate
 Early distinction was made between disorders caused by
physical factors and those caused by
emotional/psychological factors
 Psychosomatic (later, psychophysiological) disorder:
psychological factors affect somatic function, suggesting
they are caused by mental, not physical, problems
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
History (cont.)
 20th Century
 Harsh attitudes toward developmental problems of 1920s
mellowed by 1940s
 1968: The Society of Pediatric Psychology was
established to connect psychology and pediatrics
 1976: SPP established the Journal of Pediatric
Psychology, broadening the research and theory on
physical outcomes of child health disorders to encompass
 the psychosocial effects of illness
 the interplay between psychosocial effects and illness
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Sleep Disorders
 Sleep is the primary activity of the brain during early
development
 By age 2, the child has spent nearly 14 months sleeping
and 10 months in waking activities, and the brain has
reached 90% of its adult size
 By age 5 the sleep/wake cycle is more evenly balanced
 A bidirectional relationship exists between sleep problems
and psychological adjustment
 sleep disorders can cause other psychological
problems
 sleep disorders can result from other disorders
 sleep disorders can mimic or worsen symptoms of
major disorders
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Sleep Disorders (cont.)
 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
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Sleep Disorders (cont.)
 Maturational Changes
 Sleep 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 and adults 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
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Sleep Disorders (cont.)
 Features of Sleep Disorders
 Result from abnormalities in the body’s ability to regulate sleepwake mechanisms and the timing of sleep rather than the result
of medical disorder, mental disorder, or use of medication
 Dyssomnias: Disorders of initiating or maintaining sleep,
characterized by difficulty getting enough sleep, not sleeping
when one wants to, not feeling refreshed from sleep
 involve disruptions in the sleep process
 complain of sleepiness or insomnia
 many of these problems resolve themselves as the child
matures
 quite common in childhood, with the exception of
narcolepsy
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Sleep Disorders (cont.)
 Features of Sleep Disorders (cont.)
 Parasomnias: Disorders in which behavioral or physiological
events intrude on ongoing sleep
 involve physiological or cognitive arousal at inappropriate
times during sleep-wake cycle
 complaints of unusual behaviors while asleep
 common afflictions of early to mid-childhood; children
typically grow out of them
 include nightmares (REM parasomnias) and sleep terrors
and sleepwalking (often referred to as arousal
parasomnias)
 Diagnosis requires clinically significant distress/impairment; the
disturbance cannot be better accounted for by another mental
disorder, effects of a substance, or general medical condition
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Sleep Disorders (cont.)
 Treatment
 Behavioral interventions teach parents to attend to child’s need
for comfort and reassurance, gradually withdraw more quickly
after saying goodnight (extinction), establish good sleep
hygiene appropriate to child’s developmental stage and family’s
cultural values, then use positive reinforcement for
maintenance
 Identify suspected causes of disrupted sleep and involve
other family members in routine (e.g., bedtime rituals of
reading, singing, etc.)
 Behavioral interventions for circadian rhythm disorders can be
effective when adolescent and family are highly motivated
 Treatment of nightmares: provide comfort at the time of
occurrence and attempt to reduce daytime stressors
 Parents of sleepwalkers should take precautions to avoid
chances of child being injured; brief afternoon naps may help
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
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; not due to general medical condition or the
result of a diuretic
 Three subtypes:
 nocturnal only: most common; wetting occurs only
during sleep at night
 diurnal only: passage of urine during waking hours,
more common in females; believed to be associated
with social anxiety or preoccupation with a school
event
 combination of nocturnal and diurnal
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Elimination Disorders (cont.)
 Enuresis (cont.)
 Prevalence and Course
 13-33% of 5-year-old children wet their beds, boys more
than girls; by age 10, 3% of males and 2% of females;
declines to 1% of males and females by late adolescence
 diurnal enuresis is much less common
 more common among less educated, lower SES, and
institutionalized children
 primary enuresis: has continence never been attained (85%
of children with enuresis); secondary enuresis: control was
established and then lost (less common)
 associated psychological distress depends on limitations on
social activities, effects on self-esteem, and parental
reactions
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Elimination Disorders (cont.)
 Enuresis (cont.)
 Causes and Treatment
 Causes include deficiency of antidiuretic hormone (ADH),
immature signaling mechanism, and genetics
 Treatments
 Standard behavioral training methods using either
operant conditioning or classical conditioning
(especially the urine alarm used in conjunction with
other behavioral activities and dry-bed training)
 Medications: desmopressin (synthetic ADH);
unfortunately it has a high relapse rate when
discontinued
 Psychological interventions (especially behavioral) are
more effective than medications or waiting for the child
to grow out of the problem
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Elimination Disorders (cont.)
 Encopresis
 The passage of feces into inappropriate places at least once
per month for 3 months in a child at least 4 years old; not due to
organic or general medical condition
 2 DSM-IV-TR subtypes: with or without constipation (more
common) and overflow incontinence
 Prevalence and Course
 occurs in 1.5%-3% of children; 5-6 times more common in
boys; declines rapidly with age
 primary (child has reached age 4 without establishing fecal
continence); secondary (a period of continence was
previously established)
 20% of children with encopresis show significant
psychological problems, but the problems likely result from,
rather than cause, the encopresis
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Elimination Disorders (cont.)
 Encopresis (cont.)
 Causes and Treatment
 Causes include
 avoiding, suppressing, not recognizing signs when it is
time for a bowel movement, which can cause
megacolon (built up feces) and problems with
decreased signals and painful bowel movements;
 abnormal defecation dynamics that, combined with
avoidance, increases risk for chronic constipation and
encopresis
 Treatment includes combined medical and behavioral
interventions beginning with fiber, enemas, or laxatives to
disimpact the rectum, followed by behavioral and
biofeedback interventions to establish healthy elimination
patterns
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness
 A chronic illness is one that persists for more than 3 months or
requires hospitalization for more than 1 month
 10-20% of youths under age 18 experience one or more chronic
health conditions; approximately 5% suffer from a disease so
severe that it regularly interferes with daily activities
 DSM-IV-TR categories (somatoform disorders and psychological
factors affecting physical condition) have limited applicability to
children
 Somatoform disorders (e.g., somatization, hypochondriasis,
and pain disorders) involve physical symptoms that resemble or
suggest a medical condition but lack organic or physiological
evidence
 multiple somatic complaints from children may be
developmental precursors to adult somatoform disorders
 Psychological factors affecting physical condition: psychological
factors are presumed to cause or exacerbate a physical
condition
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 If medical condition is accompanied by significant adjustment
or behavior problems, child may be diagnosed with an
adjustment disorder
 Progress in developing effective medical treatments and
cures for children with chronic illness has prolonged the lives
of many who would have died during infancy or childhood
 These advances have also led to greater child and adult
morbidity; that is, the various forms of physical and functional
consequences and limitations that result from an illness
 Attention has moved from acute, infectious diseases to
emphasis on promoting children’s health and development
and assisting in the care of children with chronic health
disorders
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 Normal Variations in Children’s Health
 Children experience pain in the same ways as adults
 Children may use pain for secondary gains
 Children often express fears, dislikes, and avoidance
through somatic complaints
 Girls report more symptoms of pain and anxiety
 Family influences (social learning) can impact children’s
expressions of pain and symptoms (family pain models)
 Viewing chronic illness as a form of major stress that
requires adaptation helps researchers identify factors that
promote successful adaptation to chronic illnesses
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 Normal Variations in Children’s Health (cont.)
 Chronic health disorders and conditions affect 10-20% of
children (about 1/3 have moderate to severe conditions)
 asthma is the most common chronic illness in childhood,
followed by neurological and developmental disabilities
and behavioral disorders
 social class and ethnicity do not influence who is affected
by chronic illness, with the exception of specific conditions
genetically determined by racial or ethnic descent (e.g.,
sickle cell disease)
 children of lower SES have lower survival rates,
especially for cancer
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 Diabetes Mellitus
 Insulin-dependent diabetes mellitus is a lifelong metabolic
disorder in which the body is unable to metabolize
carbohydrates as a result of inadequate pancreatic release of
insulin
 Treatment regimen of insulin injections, diet, and exercise and
metabolic control is intrusive and can be especially difficult
during adolescence
 Despite improved treatment, the condition is still associated
with significant morbidity and mortality, including twice the risk
of cardiovascular disease
 No gender differences; rates of the disease are increasing, with
today’s children having a one in three chance of being
diagnosed with diabetes in their lifetime
 Behavioral strategies help promote regimen adherence,
metabolic control, and family adaptation; reinforce symptom
reduction or medication use, and self-control methods
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 Childhood Cancer
 In comparison to adults, onset in children is more sudden and
the disease is often at a more advanced stage when first
diagnosed
 Most common form is acute lymphoblastic leukemia (ALL)
 Despite dramatic improvements in survival rates due to
treatment advances, long-term complications from recurrent
malignancy, growth retardation, neuropsychological deficits,
cataracts, and infertility continue to pose a risk to survival
 Requires intensive medical treatment, especially during the first
2-3 years
 Approximately 80% of pediatric cancer patients survive; 50%
will have serious physical or mental illness as adults and will
require long-term care
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 Development and Course
 Children with chronic illness have 2.4 times higher risk for
psychiatric disorder than healthy children; children with
chronic illness accompanied by disability are at greatest
risk
 primarily internalizing problems (anxiety and
depression); externalizing problems such as ADHD
also evident
 Most children adapt successfully to their illness and show
considerable resilience
 symptoms of anxiety, depression, and anger are
normal responses to stressful experiences associated
with chronic illness and treatment regimens, rather
than psychiatric disorders
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 Development and Course (cont.)
 Effect on Family Members
 The child’s illness may result in family cohesion and support
or in family disruption and crisis
 Chronic illness may precipitate PTSD in family members
(about 10% of parents), although typically the children
themselves don’t suffer PTSD-related symptoms
 Healthy parental adjustment and ability to help the child
develop autonomy and control are related to healthy child
adjustment and adherence to treatment regimen
 Perceived social support and parental adaptation are key to
helping children lower their stress and increase coping
 Siblings of children with a chronic illness experience
heightened social and mental health problems
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 Development and Course (cont.)
 children with severe, disruptive illnesses suffer most in
terms of social adjustment
 children with chronic illness may demonstrate academic
problems, which may be due to primary effects of the
illness, or to secondary effects, such as absenteeism,
fatigue, or psychological stress
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 Social Adjustment and School Performance
 Adjustment is reflected in terms of psychological distress and
through developmental accomplishments in social adjustment,
peer relationships, and school performance
 Maladjustment may be expressed by displaying submissive
behavior with peers and engaging in less social activity
 Peer support facilitates adaptation and is linked with healthpromoting behaviors
 Social adjustment problems are linked to CNS illnesses
because they impact cognitive abilities such as social judgment
 Problems with school adjustment and performance may stem
from primary effects of the illness or its treatment and
secondary consequences, such as fatigue or psychological
stress
 About 50% of children with brain-related illnesses are in special
education settings
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 How Children Adapt: A Biopsychosocial Model
 The transactional stress and coping model takes into
account:
 Illness parameters: type of illness, severity, including
visible disfigurement and functional impairment
 Demographic parameters: including gender, age, and
SES
 Child and family processes mediate the illness-outcome
relationship; psychological mediators: parental
adjustment, child adjustment, and their interrelationship
 The illness parameters that play the most significant role
in children’s adjustment are severity, prognosis, and
functional status (children and family members’ personal
characteristics and family adaptation and functioning)
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 How Children Adapt: A Biopsychosocial Model (cont.)
 The transactional stress and coping model (cont.)
 Personal characteristics: boys show more adjustment
problems than girls, although girls have more anxiety,
depression, negative perceptions of physical appearance
 current age, age at onset, economic and health
disparities, intellectual ability and acquired strengths in
self-concept and coping skills, accurate appraisal of
perceived stress
 Family adaptation and functioning: child adjustment
depends in part on degree of stress and symptoms
experienced by other family members (especially primary
caregiver)
 parental adaptation is key: how parents manage stress,
parental coping strategies, degree of support and
cohesion among members, and availability of utilitarian
and psychological resources
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Chronic Illness (cont.)
 Intervention
 Psychosocial interventions help children and their families
reduce and manage stress, enhance social problem-solving
skills, learn child-rearing practices, and become empowered
 Empowering families reduces stress and dependency, and
enables families to obtain the necessary information to make
informed decisions and take competent actions
 Support groups and educational programs
 Treatment-related activities based on needs of the family
 Helping children cope: Parent involvement and maternal
adaptation are key to children’s coping
 Two main psychological approaches to helping children
cope with stressful medical procedures and chronic and
recurrent pain are providing information and training in
coping skills
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Adolescent Substance Use Disorders
 SUDs in adolescence include substance dependence and
substance abuse, resulting from self-administration of any
substance that alters mood, perception, or brain functioning
 Can lead to psychological and physical dependence
 For a diagnosis of substance dependence, must show a
maladaptive pattern of substance use for at least 12 months,
with three or more significant clinical signs of distress such
as tolerance or withdrawal
 Criteria for substance abuse involve one or more harmful and
repeated negative consequences of substance use over the
last 12 months; diagnosis of substance abuse is not given if
the individual meets criteria for substance dependence
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Adolescent Substance Use Disorders (cont.)
 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; use of
hallucinogens and inhalants has decreased somewhat
 8% of adolescents aged 12-17 met criteria for substance
abuse or dependence in 2001 survey
 The rates are much higher (approximately 33%) for young
people with histories of other mental health problems, or
involvement with child welfare or juvenile justice systems
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Adolescent Substance Abuse Disorders (cont.)
 Prevalence and Course (cont.)
 Age of onset:
 Some amount of substance use during adolescence is
normative behavior (although experimentation is not
harmless)
 Critical risk factor is age of first use: the odds of developing
alcohol dependence decreased by 9% for each year that
onset of drinking is delayed; alcohol use before age 14 is a
strong predictor of subsequent alcohol abuse or
dependence
 Sex and ethnicity: Sex differences in lifetime prevalence rates
are converging due to increased substance use among girls
 African American youth have substantially lower usage
rates than whites; Hispanics fall between the two, although
highest rate of lifetime usage for powder cocaine, crack
cocaine, heroin, methamphetamines
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Adolescent Substance Use Disorders (cont.)
 Prevalence and Course (cont.)
 Course: Rates typically peak around late adolescence then
decline during young adulthood
 Greatest concern is when high-risk behaviors begin well
before adolescence, are ongoing, and occur among peer
group with similar behaviors
 Alcohol use influences involvement in other high-risk
behaviors, especially unsafe sexual activity, smoking, and
drinking and driving
 Girls who report dating aggression are 5 times more likely to
use alcohol than girls in nonviolent relationships; boys are
2.5 times more likely
 Also associated with sexual intercourse at earlier age, more
sexual partners, greater risk of STDs, unhealthy weight
control, suicidality, and mood and anxiety disorders
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Adolescent Substance Use Disorders (cont.)
 Prevalence and Course (cont.)
 Associated characteristics: using more than one drug
simultaneously, poor academic achievement, higher rates
of academic failure, higher rates of delinquency,
disruption of neurodevelopmental processes, and high
comorbidity with ADHD and conduct problems
 Causes
 Personality characteristics such as increased sensation
seeking: 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
disconnectedness
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Adolescent Substance Abuse Disorders (cont.)
 Causes (cont.)
 Family Functioning:
 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
 trust between adolescent females and their parents is
a strong deterrent for risk behaviors
 other risk factors: parental history of substance abuse,
poor parent-teen communiciation, family conflict
 Peers and Culture: association with deviant and
substance-using peers; false consensus (“everyone’s
doing it”), substance use glamorized by peer culture
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Adolescent Substance Use Disorders (cont.)
 Treatment and Prevention
 About 50% of patients for SUDs relapse within first three
months, and only 20-30% remain abstinent
 Family-based approaches that seek to modify negative
interactions 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
 Effective approaches address multiple risk factors from
influences of the individual, peer, family, school, and community
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Adolescent Substance Use Disorders (cont.)
 Treatment and Prevention (cont.)
 Life skills training emphasizes building drug resistance
skills, personal and social competence, and altering
cognitive expectancies around substance abuse
 Prevention programs target social environment via
community and school norms, and include parent
involvement and education to improve parent-child
communication about substance use
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning