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Chapter Summary
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It is common for children to exhibit some difficulty in acquiring habits of elimination, sleep,
and eating. For some children, these problems are serious enough to be of clinical concern.
Problems of Elimination
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Toilet training is an important concern for parents of young children. Knowledge of the typical
sequence of control over elimination and of appropriate parenting practices can contribute to
successful training.
Enuresis and encopresis are disorders of elimination that seem best explained by a
combination of biological pre-disposition and failure to train and/or learn bodily control.
Desmopressin is the best-supported medically oriented procedure for treating enuresis.
Behavioral interventions that include a urine-alarm procedure have high success rates and low
rates of remission, and they are the treatments of choice at present.
Encopresis is probably best dealt with through a combination of medical and behavioral
procedures.
Sleep Problems
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Sleep problems are common in infants, children, and adolescents. Sleep disorders are
persistent sleep difficulties that cause the child distress or interfere with other functioning.
Difficulties in initiating and maintaining sleep may be related to neurophysiological
development, but are probably also affected by environmental influences such as bedtime
routines and the appropriate cues for sleep. Sleep disorders such as sleepwalking and sleep
terrors (parasomnias) are probably best conceptualized as resulting from a combination of
nervous system immaturity and environmental factors.
Problems of Feeding, Eating, and Nutrition
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A wide range of problems having to do with eating and feeding are commonly reported in
young children. Many of these problems cause considerable concern for parents and
appreciable disruption of family life.
Some eating and feeding problems are more serious and persistent, and may actually
endanger the physical health of the young person.
The early feeding and eating disorders in the DSM are Rumination Disorder, Pica, and Feeding
Disorder of Infancy or Early Childhood, which is also often discussed as failure to thrive.
Childhood obesity is quite prevalent. It is an important health problem that may be associated
with a variety of physical, social, and psychological difficulties. The development of obesity is
influenced by a complex interaction of biological, psychological, and socio-cultural influences.
The learning of adaptive eating and activity patterns is the basis of behavioral treatment
programs for obesity. This approach to treatment is probably the most successful. However,
greater weight loss and better maintenance still need to be achieved, and priority needs to be
given to prevention and early intervention.
Eating Disorders: Anorexia and Bulimia Nervosa
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Weight status, the presence or absence of binge eating, and the method employed to control
one’s weight are important considerations in thinking about eating disorders.
The DSM describes two primary eating disorder diagnoses: Anorexia Nervosa and Bulimia
Nervosa. Eating Disorder Not Otherwise Specified (EDNOS) and Binge-Eating Disorder are also
described.
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Anorexia nervosa (AN) is a serious disorder characterized by extreme weight loss, an intense
fear of becoming fat, and disturbance in the perception of body weight and shape. A number
of other physical and psychological problems are present as well. A distinction is made
between restricting and binge-eating/purging anorexia.
Bulimia nervosa (BN) refers to a repeated pattern of binge eating followed by some
inappropriate compensatory mechanism. A distinction is made between purging and
nonpurging types.
Females represent about 90% of all cases of eating disorders (AN and BN). EDNOS may be
more common than AN or BN among youths. Increasing prevalence of eating-disordered
behavior and attitudes among young girls has been noted. There is also increased concern
regarding disordered eating and body dissatisfaction in young males.
Ethnic and cultural differences deserve further consideration and certain groups, such as some
athletes and dancers, may be at particular risk.
Depression, anxiety disorders, and substance abuse commonly co-occur with eating disorders.
Age of onset for AN is typically during adolescence. For many individuals the disorder, or other
eating problems, persists over a considerable period of time. Significant medical complications
may occur and for some, the disorder may be life threatening.
The onset of BN extends from adolescence into early adulthood. Although symptoms diminish
for many individuals, there is concern regarding persistent eating difficulties and depression.
Also, various medical problems may occur particularly among those who purge.
Explanations that incorporate multiple influences are needed to understand the development
and maintenance of eating disorders. Genetic and other biological influences, early feeding
difficulties, weight history, cultural influences, and family influences are among the influences
to consider.
Treatments for BN specific to adolescents have received limited attention, and current
treatment recommendations are therefore based largely on downward extensions of studies
with adults.
The use of family therapy or family involvement in treatment is widespread in clinical practice,
but empirical support is more limited. The Maudsley approach to treating AN is the beststudied family therapy.
Cognitive-behavioral treatment is the intervention for BN for which there is the best research
support. A similar program for individuals who may fall in the subclinical or EDNOS category
has been developed. Interpersonal psychotherapy has also proven to be effective with young
adults.
Controlled studies regarding the effectiveness of pharmacological treatments for eating
disorders in adolescents is limited and findings unclear.
Empirical studies of prevention of eating disorders are relatively limited.