1. Pediatric Psychology & Health-Related Disorders

2. What is pediatric psychology?
APA division 54 Society for Pediatric Psychology
Science and practice in which the principles of psychology are applied within the context of pediatric health.
The field aims to promote the health & development of children, adolescents, & their families through use of evidence-based methods
Notes: this is an entire subfield of child clinical psychology. In summary, it deals with the psychosocial components of disorders and illness often physical in nature– health psychology applied to children.

3. What is pediatric psychology?
Areas include, but are not limited to:
psychosocial, developmental and contextual factors contributing to the etiology, course and outcome of pediatric medical conditions
assessment and treatment of behavioral and emotional concomitants of illness, injury, and developmental disorders
prevention of illness & injury;
promotion of health & health-related behaviors;
education, training & mentoring of psychologists and providers of medical care;
improvement of health care delivery systems and advocacy for public policy that serves the needs of children, adolescents, & their families.
Notes: Notice that pediatric psychology deals with a wide range of topics including recovery from illness, prevention, etc.

4. Chronic Medical Conditions (examples)
Asthma
Childhood Diabetes
Pediatric Oncology
HIV/AIDS
Cardiovascular disease
Juvenile Diabetes
Obesity
Notes: Think about the potential role of psychologists to help children who are experiencing any of the above illnesses/diseases. For example, how many of the above are impacted by stress or impacted by lifestyle (behaviors)?

5. Issues often addressed
Adaptation to illness
Adherence
Pain
Family systems & peer relationships
Medication issues
Notes: Pediatric psychologists may help children and families with adaptation to chronic illness. Think about the stress and fear and change in lifestyle that may come with a diagnosis (think of the previous slide). Adherence is a really important topic. What can happen if a child with diabetes is non-adherent? The outcome can be dangerous. What about adherence to HIV mediation. Poor adherence can actually cause the virus to mutate and become more treatment resistant. Other topics include pain management, and getting families to help with adherence.

6. Example: Diabetes Mellitus in Children & Adolescents
Type 1 diabetes (formally insulin dependence)
Type 2 (non-insulin dependent)
Notes: Type I diabetes is an example of a disease in which pediatric psychologists are often involved. Complex, consistently treatment regimens and strict diets are often necessary. Not following results in negative (often severe) health-related consequences.

7. Diabetes: Psychosocial Intervention
Diabetes management
Knowledge
Skills
Treatment adherence
Notes: Psychologists often work with the child and family to develop knowledge (psychoeducation) and to make sure that they have the skills (e.g., to administer treatment). They often work with the family regarding treatment adherence. This can be challenging. Many families already have chaotic schedules. Imagine adding a strict diet and medication management for one of your children. Now imagine a family that is lower functioning/dysfunctional and/or has limited resources. It can be hard to get them to adhere. As children get older the responsibility for adherence eventually shifts to the child. Even in a well functioning family, imagine trying to get a teenager to adhere to a treatment regimen for diabetes. Teenagers are sometimes forgetful and/or rebelous, and/want to be like other adolescents in terms of what they eat, and/or see themselves as invincible.

8. Diabetes: Psychosocial Intervention
Stress, Coping, & Psychological Adjustment
Social Context
Peers
Family involvement
Notes: For a lot of physical disorders/illnesses including diabetes it may be important to help the individual manage their stress and monitor psychological adjustment, as these factors influence health outcome in a number of ways. Also, as mentioned in previous slides family and even peer involvement may need to be addressed.

9. Health-Related Disorders
This is a category of problems/disorders that often fall under the category of pediatric psychology; however, are also frequently addressed by pediatricians and or general child mental health practitioners.
Common examples include problems, concerns with eating, toileting, & sleeping.
Two basic topics will be briefly covered:
Enuresis & encopresis (toileting)
Sleep problems

10. Enuresis & Encopresis
Notes: Enuresis has to do with urinating (mostly bedwetting) outside of expected developmental normal. Encopresis has to do with bowel movements in inappropriate places outside of expected developmental norms.
In both cases, before you treat from a psychosocial perspective, make sure that it is not a medical problem (have them cleared medically).

11. Enuresis Normative development
Daytime bladder training usually completed around 36 months
Occasional bed wetting, 5-13 years:
7% of boys & 6% of girls wet bed at least 1x/week.
16% of boys & 12% of girls wet bet at least 1x/3months.
Notes: Normative development is an important component of this discussion. Most children are fully toilet trained between the ages of 2 and 3. Bowel training sometimes takes longer. Parents often want to rush toilet, but it is probably not a good idea. Toilet training requires a certain level of readiness (level of physical development). When starting, parents should try to minimize stress and tension and focus on positive reinforcement. Also notice that some bedwetting is normal!!!!

12. Enuresis- Prevalence & course
5 year-olds (7% of boys, 3% of girls)
15% decline in prevalence each year
Percentage of children who meet diagnostic criteria for enuresis:
Age 5 – 5% to 10%
Age 10 – 3% to 5%
Age 15 – 1%
Notes: Notice that many children outgrow it over time. Having said that, not intervening (after the child is clearly outside typical developmental window) can have some negative consequences.

13. Treatment Urine alarms Behavioral interventions:
bedwettingstore.com
Behavioral interventions:
Rewards, cleanliness training
Retention control training
Medication
Imipramine (an antidepressant sometimes prescribed off label.
Notes: Urine alarms work very well, especially with behavioral training. Check out the betwettingstore website. I bet you never knew that there were so many bedwetting products. Seriously check out the alarm. You can sample the alarm settings. Cleanliness training has to do with getting the child to take responsibility by helping out with the cleaning. Retention control training is used to strengthen the bladder muscles. Imipramine seems to help, but I would recommend behavioral interventions first.

14. Notes: There are a number of variations of the alarm
Notes: There are a number of variations of the alarm. There are pads that can go on the bed and there are sensors that attach to the underwear. The alarm detects moisture and rings. This wakes up the child. A conditioning seems to take place in which the sensation of having to go eventually wakes the child up without the need for the alarm (probably classical conditioning).

15. The Bedwetting Alarm
Notes: Another example.

16. Encopresis Two subtypes
Constipation and overflow incontinence (most cases)
Without constipation and overflow incontinence
Notes: Remember this is bowel movements in inappropriate places, mostly pants and mostly during the day. To diagnose behavior must occur outside of typical developmental window for toilet training. Overflow incontinence is probably the most medical. It requires medical attention first, then psychosocial intervention as follow-up.

17. Characteristics & Prevalence
About 1% of 5-year-olds
More boys than girls experience encopresis

18. Etiology
Chronic constipation is the foundation of most children’s encopresis (leads to blockage and overflow)
Constipation may be caused by a genetic predisposition or by a diet low in fiber
Stool-toilet refusal can result in constipation

20. Interventions Medical exam and intervention
Medical practitioners clear impacted stools & restore normal functioning
Behavioral
Modified diet
Behavioral toilet training (e.g., reward system)
Toileting schedule
Notes: Medical intervention first, followed by psychosocial.

21. Sleep Disorders
Sleep disorders is a large group of disorders, a few that are most common in childhood will be discussed.
Keep in mind that sleep problems are a common complaint from parents. Much of this is normative, and although it will continue, it can often be managed through basic behavioral intervention.

22. Notes: Notice that sleep is dynamic
Notes: Notice that sleep is dynamic. It is dynamic in that the nature of sleep changes from one developmental stage to the next. It also changes over the course of the night (we experience more REM sleep as we continue to sleep.

24. Notes: Three categories are particularly relevant to children: (1) insomnia, (2) sleep terror (under sleep arousal disorder), and (3) nightmare disorder.

25. Notes: Notice a few things
Notes: Notice a few things. First, REM sleep becomes a greater portion of the cycle later. Also, notice that nightmares often occur during REM sleep (the person awakes from REM sleep), and sleep terrors (along with other arousal disorders) typically occur during non-REM sleep. Children with sleep terrors are typically nonresponsive– don’t try to wake them, it makes them more agitated.

26. Insomnia
Notes: This is a pretty good representation of the factors that lead to and maintain insomnia.

27. Insomnia 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, and then use positive reinforcement for maintenance

28. Insomnia Treatment
Notes: I always thought the term sleep hygiene was not a very good term (sound like it means that you shower and have clean sheets). Anyway, these are good sleep habits that help with insomnia. They also help with general difficulties in getting children to go to sleep. I think some of the most important include getting the child to go to bed and to wake up around the same time to maintain circadian rhythm and minimizing simulation before bedtime (T.V. stimulates the visual cortex too much), reading is better.

29. Treatment: Other sleep disorders
Treatment of sleep terrors:
Attempt to reduce daytime stress & excessive fatigue & stress
Brief afternoon naps may be beneficial
Do not try to wake!!!!! They become more agitated.
Treatment of nightmares:
Provide comfort at the time of occurrence, attempt to reduce daytime stressors & excessive fatigue & stress
Treatment of sleepwalkers:
Take precautions to avoid chances of child being injured, reduce excessive fatigue & stress