Paediatric psychology is concerned with the investigation of (psychological) problems leading to disruption of physical function and health.
Problems with toilet training and learning sleeping and eating habits are common. Both the ability of the child to master these skills and the skills of parents to guide the child in this are important for the well-being of the child and parents. Sometimes parents seek help if they are unable to learn certain habits.
Potty training
The usual order in which children get toilet training is as follows: control of the intestines at night, control of the intestines during the day, control of the bladder during the day and control of the bladder at night. Although there is considerable variation in the age at which children become toilet-trained, they are often toilet-trained between the ages of 1.5 and 3. Parents disagree about when or at what age it is good to start toilet training. This decision often depends on cultural values, attitudes and daily circumstances, such as requirements for childcare and the presence of other siblings.
There are various factors that contribute to good toilet training. First of all, it is important that parents are able to determine when the child is ready for development. In addition, the parents must be able to properly assess when the child needs to go to the toilet. Thirdly, they must prepare well for toilet training, for example by having the child wear clothing that can be easily taken off. Finally, it is effective to positively reinforce the child.
Enuresis refers to a lack of control over the bladder, during the day and / or at night, that cannot be explained by a physical disorder. Often the diagnosis can only be made after the age of 5. The diagnostic criteria also state that there must be a certain frequency of the control deficiency and this frequency varies with the age of the child. It must be done at least twice a week and for three months or there must be a clinically significant disruption of daily functioning.
A distinction is made between urinating in bed and urinating during the day and between primary and secondary enuresis. Enuresis is called primary, if the child has never been toilet trained, and secondary if the child has been toilet trained. About 85% of the cases belong to the bedwetting category or the primary type.
Epidemiology
About 10% of children of primary school age show enuresis. The prevalence decreases with age and is 1% for men at the age of 18 and less than 1% for women. The problem occurs at least twice as often among boys than among girls.
Aetiology
It used to be thought that enuresis was the result of emotional problems. However, there is no evidence for this. If there are emotional problems, these are usually the result rather than the cause of enuresis. Children who exhibit enuresis often have problems with peers and other family members. Enuresis and emotional problems can also occur together, because similar factors, such as a chaotic family environment, contribute to the development of both problems.
The most common explanation for enuresis is a developmental delay in the ability to recognize the feeling of a full bladder while sleeping. In addition, it is sometimes suggested that sleeping problems contribute to the development of enuresis. For example, parents often assume that bedwetting occurs because children sleep deeply. However, bedwetting can occur at any stage of sleep, not just at the stage of deep sleep. This doubts whether enuresis is a sleep arousal disorder. Enuresis in a subgroup of children may be the result of sleep arousal patterns.
It has also been suggested that there is a decreased bladder capacity or a higher urine output in the case of enuresis, because the antidiuretic hormone does not increase during sleep. Although the evidence for this is inconsistent, in some cases it may be one of the factors that plays a role. There is also evidence for a genetic contribution to enuresis. In general, therefore, some children appear to have a biological predisposition to enuresis, which may be expressed depending on different environmental factors.
Behavioural theories of enuresis state that enuresis is due to an inability to control reflex urinating behaviour. This can be the result of poor toilet training or other environmental influences that interfere with the training, such as a stressful home environment. Most behavioural theories also contain a biological component.
Therapy
It is important to, first of all, have a doctor rule out that a child with enuresis has a medical problem. Pharmacological treatment is often used in the treatment of enuresis. Today, the most commonly used drug against enuresis is desmopressin acetate (DDVAP), which controls the excessive excretion of urine during sleep. This drug has a low risk of side effects. However, if the medication is stopped, there tends to be a relapse.
The most well-known behavioural treatment is the urine alarm system, which goes off when liquid is absorbed by sheets. When a child pees in bed, the alarm goes off and the parents wake the child up. The child goes to the toilet to pee. Then the bed is changed, and the child goes to sleep again. The device is removed after having slept for fourteen nights. In the vast majority of cases it is effective, and it is also more effective than medication such as DDVAP. After completion of the treatment, a relapse occurs in only 40% of the cases. Restarting the training often ultimately leads to a complete recovery.
To prevent relapse in children, some changes have been made to the standard urine alarm procedures:
Encopresis occurs when a child relieve themselves in their own pants or other places should not be used for relief. This disorder is not the result of a physical disorder. The diagnosis is made if the event occurs at least once a month for a child of 4 years or older and should be consistent for at least three months. There are two sub-types encopresis: encopresis with constipation and encopresis without constipation. The vast majority of children are chronically congested and are classified as congested with incontinence ('retentive encopresis').
Epidemiology
The prevalence estimates of encopresis vary between 1.5% and 7.5%. The prevalence diminishes with age and encopresis is rare in adolescence. Encopresis is more common in men than in women.
The majority of children with encopresis do not suffer from psychopathology. However, because encopresis occurs more often during the day than at night, it is accompanied by a social stigma. Therefore it can be associated with more behavioural problems. If there are psychological problems, this is often the result rather than the cause of encopresis. It can also occur that psychological problems and encopresis are the result of common environmental factors, such as family stress.
Aetiology
There are several causes of encopresis. Constipation can be influenced by factors such as diet, fluid intake, medication, stress and incorrect toilet training. The hard stools can cause the rectum and colon to swell, causing the intestines to prevent the body from using the normal bowel reflex (which is used for normal amounts of stool).
Medical perspectives emphasize a neuro-development perspective. For example, encopresis occurs faster in people who have abnormalities in the structure or functioning of the physiological and anatomical mechanisms that are needed for stool control. These deviations are considered temporary.
The behavioural perspective emphasizes incorrect toilet training, possibly in combination with poor nutrition. Encopresis can result from the inconsistent use of toilet training. It may also be that encopresis is maintained by learning principles, such as avoidance of pain or anxiety or positive reinforcement.
Therapy
Many encopresis treatments combine medication with behavioural therapy. Parents are asked to schedule regular toilet times. If necessary, they can use suppositories. To promote bowel movements, changes in fluid intake, diet and laxatives are used. Positive effects should be used to reward the child. When children relieve their pants, the child must change his or her own clothes. Later in the treatment, laxatives and suppositories are no longer used. This method of treatment is very effective, and relapse is rare. If encopresis is used to manipulate the environment (for example, to get more attention from the parents), additional family therapy is important.
Dyssomnia
A distinction can be made between two types of sleeping problems:
Problems with falling asleep or falling asleep are common. If these are severe and chronic enough, this is called insomnia. These sleeping problems are considered to be manifestations of the child's neurophysiological development and, therefore, these problems are expected to end up on their own. However, in some cases, child, parent and environmental factors play a role. For example, if a parent always cradles a young child asleep, the child does not learn to fall asleep. These problems can be persistent and can lead to limitations in the social, school and other areas of functioning. Sleep problems can be related to other problems. In this way fears or worries can contribute to problems falling asleep and falling asleep. Sleeping problems can also be part of the manifestation of disorders such as ADHD, autism, depression and anxiety. Another explanation for the combination of sleeping problems and other problems is that both manifestations can be of common etiological mechanisms, such as a difficult temperament or parenting practices.
There are various effective interventions for dyssomnia. Parents learn to put the child to bed at a fixed time and to develop fixed routines. Once the child is in bed, the parents should ignore the child until an agreed time the next morning. This cancellation procedure is based on the assumption that attention paid to the troubles by the parents will maintain the sleeping problems in the child. Some parents find it too difficult to ignore the child for a long time, for example when he or she cries. In that case, gradual extinction can be used. First of all, parents ignore the crying as long as they can (the time is agreed upon in advance) and after a number of nights this time is extended. Moreover, the development and worsening of sleeping problems can partly be prevented by providing parents with information about sleep, the importance of routines and the importance that the child learns to put himself to sleep.
The most commonly used treatment is medication. However, there is a lack of evidence for the effectiveness of pharmacological treatments. In addition, there are concerns about the negative side effects and the recurrence of sleeping problems if treatment is discontinued. It is therefore recommended to first apply behavioural treatment.
Parasomnia
Sleep arousal disorders (parasomnia) include problems such as sleep walking and sleep panic. Sleep walking (somnambulism) starts when a child sits up in bed, opens his or her eyes, but is not aware of what he or she sees(not awake). Often the child gets out of bed and then walks through the house,, performing several habitual actions but that does not necessarily have to happen. During sleepwalking the child may not respond to stimuli. In most cases, the child cannot remember afterwards that he or she has been walking around, which can lead to confusion or stress (for example, if the child wakes up in a room other than where he or she went to sleep). Sleep walking can have risks for physical health.
Approximately 15% of children between the ages of 5 and 12 have ever been sleep walking. A sleep walking disorder (persistent sleep walking) occurs in 1-6% of the population. This problem usually lasts for several years and often disappears in adolescence.
Often children tend to sleepwalk during the first one to three hours after falling asleep. The fact that sleep walking occurs in the later stages of NREM sleep (deep sleep) indicates that sleep walking is not the execution of a dream, because dreams occur in REM sleep. For children sleepwalking, there is a certain EEG pattern. During the first year of life, this EEG pattern occurs in 85% of the children. However, this pattern is only found in 3% of children aged 7 to 9. It is therefore suggested that an immature nervous system plays a role in sleep walking disorders. This is supported by the fact that people often grow out of sleepwalking. However, the role of psychological and environmental factors is not excluded. For example, the frequency of sleep walking is affected by insufficient sleep, changes in sleeping habits, the specific setting, stress and physical illness. In addition, sleep walking has a strong genetic component.
Sleep panic (aka sleep terrors) occurs in 3% of the children. It often occurs between the ages of 4 and 12 and children grow out of this problem. Sleep panic often develops about 2 hours after falling asleep. While the child is sleeping, he or she suddenly sits up in bed and screams. There are often signs of autonomous arousal, such as rapid breathing and dilated pupils. The child can also repeatedly perform certain motor movements and may appear disoriented and confused. Usually the child goes back to sleep automatically, without waking up completely, and he or she remembers little to nothing about the event the next morning. The same factors seem to play a role in the development of sleep panic as sleep walking. In addition, both occur in the same part of the sleep cycle.
Nightmares often occur in 3- to 6-year-old children during REM sleep. There is a fear reaction during sleep. It is suggested that the dreams are a direct expression of the child's fears. It is still unclear what the causes of nightmares are. Several factors, such as physiological and environmental factors, probably play a role.
Both sleeping panic and nightmares are fear reactions during sleep. Both are often confused with each other, but they differ from each other in several ways:
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Sleep walking and sleeping panic often do not require intensive treatment, as it often disappears on its own. Examples of treatments are the use of instructional procedures and anxiety-reducing procedures. Cognitive behavioural techniques are also often used to treat nightmares to reduce anxiety.
From obstructive sleep apnoea occurs when a person repeatedly, while asleep, stops breathing entirely. Symptoms include snoring, breathing breaks, breathing problems, restless sleep, sweating while sleeping and bed wetting. In addition, during the day there may be fatigue, breathing through the mouth, chronic nose cold and headache. Sleep apnoea occurs especially during REM sleep later in the night. Parents are often not aware of the symptoms that occur during sleep. Instead, they complain about problems such as sleepiness, behavioural problems, hyperactivity, inattention and academic problems.
Obstructive sleep apnoea is a common sleep disorder. The prevalence is highest among 2 to 6-year-old children and in adolescence. In young children, enlarged throat and nose tonsils are often the cause of the problem. Then the removal of the tonsils helps. In adolescents and adults, the disorder is often associated with obesity. In that case, losing weight is recommended.
Young children may experience various eating problems, such as eating too little, eating too much, pickiness and problems with chewing and swallowing. Eating problems are often accompanied by behavioural problems such as tantrums, spitting and gagging. If these problems are serious, there may also be psychological and social problems and may lead to medical problems and malnutrition. Failure to thrive refers to life-threatening weight loss or failing to gain weight.
Rumination disorder
A rhythm disorder is characterized by the voluntary and repeated retching and heaving up food (rumination), without an organic cause. The child throws the head back and makes chewing and swallowing movements to bring food up. The child can also do this by putting his or her fingers down his throat or by chewing on objects. The child does not seem to be affected by this, but rather finds it pleasant. In serious cases, medical complications can arise, and it can even lead to death.
Rumination is most common among babies and people with intellectual disabilities. In normally developing children, this disorder develops in the first year of life and is considered a form of self-stimulation. Sensory and emotional deficits are associated with this disorder. The disorder arises later in people with a mental disability. The more severe the intellectual disability, the more often the disorder occurs. The disorder is more common in boys than in girls.
When treating a rhythm disorder, the emphasis is on social attention. For babies, it also helps if a mother learns to create a warm and responsive environment. Parents can easily carry out this type of treatment at home.
Pica
Pica is characterized by eating inedible things, such as paint, paper, waste, hair and bugs, out of habit. During the first year of life, babies put all sorts of objects in their mouths, partly as a way to explore the environment. In the second year of life, they learn to explore the environment in different ways and learn to distinguish between edible and non-edible things. That is why pica is often diagnosed if after this age there is persistent eating of inedible things. Pica is most common among 2- to 3-year-old children and especially among children with intellectual disabilities.
Pica can, among other things, lead to infections, intestinal obstructions and poisoning. There are various possible causes of pica, such as inattention of parents, a lack of supervision of the child and a lack of adequate stimulation. Cultural influences, such as superstitious ideas about eating certain things, can also play a role.
Informing parents about the dangers of pica and encouraging parents to reduce such behaviour is somewhat successful. In some cases, however, it is necessary to use more intensive interventions, such as behavioural interventions, that focus on the antecedents and consequences of pica.
Evasive and limiting food intake disorder.
The evasive and limiting food intake disorder is characterized by a persistent failure to eat properly, which leads to the child not gaining weight or losing a lot of weight. The problem is considered a failure to thrive. The prevalence estimates of failure to thrive in the general population vary between 3% and 10%. The disorder is more common among children with a low birth weight and children with a disability or physical illness. About as many men and women suffer from this disorder.
The evasive and limiting food intake disorder can cause physical, socio-emotional and cognitive problems. The child can be withdrawn and irritable. This can again contribute to eating problems. This disorder probably has multiple causes, including physiological, behavioural and environmental factors. Drotar and Robinson suggest that the development of an eating disorder can be conceptualized in terms of parental competence : parents' sensitivity to the child's development and communication with and involvement with the child. This competence is influenced by three factors:
The focus of treatment of evasive and limiting food intake disorder is on treating physical and diet-related factors to improve growth and development. Usually a multidisciplinary treatment is used, in which behavioural procedures play an important role.
Obesity
Obesity is usually defined in terms of the body mass index (BMI; weight or height 2 ). A BMI at or above the 85th percentile there is overweight, and from the 95th percentile of obesity. About 17% of 2 to 19-year-old children in America are overweight. Certain ethnic or racial groups have an increased risk of obesity, including Mexican American men. The prevalence of obesity has recently increased for all age groups, for both boys and girls and for all ethnic or racial groups.
Childhood obesity is related to problems in various areas:
There are several factors that lead to obesity:
The most effective treatments for obesity focus on multiple facets and emphasize behavioural interventions and education. Parent involvement is an important element. It is important to change the lifestyle of a family and to teach parents the skills needed to maintain good eating behaviour when treatment is over. In addition, improving the child's self-regulatory skills is of great importance. Although research provides evidence for the effectiveness of a versatile behavioural treatment, better interventions need to be developed that ensure more consistent and permanent weight loss. In connection with the increasing prevalence of childhood obesity, there is a need for broader social intervention and prevention programs.
Anorexia and bulimia are eating disorders where people try to control body weight in a maladaptive way. Someone who does not meet the diagnostic criteria of anorexia nervosa and bulimia nervosa can be diagnosed within the category: Eating Disorder Not Otherwise Specified (EDNOS). An example of this is Binge-Eating Disorder, in which one throws up food to not physically process it.
Different dimensions can be used to make a distinction between different eating disorders:
Anorexia nervosa
Anorexia nervosa is characterized by an extremely low weight, an extreme pursuit of thinness and fear of gaining weight. The diagnostic criteria for anorexia nervosa are as follows:
The DSM distinguishes between two subtypes of anorexia nervosa:
Bulimia nervosa
In contrast to anorexia nervosa, bulimia nervosa is characterized by a normal body weight. The diagnostic criteria for bulimia nervosa are as follows:
Compensatory behaviour consists of two types: Purging type: the person intentionally throws up and / or uses laxatives. Restrictive type: the person exhibits compensatory behaviour, such as fasting and excessive exercise. The most common method is purging, but there are also people who combine these types.
Epidemiology
Eating disorders occur primarily in young women. 90% of the cases are women. Prevalence estimates are based on the number of individuals who meet the diagnostic criteria of anorexia nervosa or bulimia nervosa (1.1 to 4% & 1.1 to 4.6%), but many others exhibit different aspects of disturbed eating behaviour and body image. Many of these people meet the criteria for an Eating Disorder Not Otherwise Specified (EDNOS), which is more common than anorexia nervosa and bulimia nervosa. These cases are sometimes described as "partial syndrome" or "subclinical". Although complete eating disorders often occur in late adolescence, disturbed eating behaviour and attitudes are already present at a younger age. These problems can be precursors of more serious eating disorders.
Eating disorders are especially common among young white women from a medium to high social class. The information regarding ethnic or racial differences between adolescents is limited. Some studies found no differences. It is suggested that eating disorders, particularly bulimia nervosa, are a culturally related phenomenon. The more westernized women from other cultures would then have a higher risk of developing an eating disorder. Within Western culture, certain groups have a higher risk, such as individuals who practice gymnastics, wrestling, ballet, or cheerleading.
Comorbidity
Eating disorders are often accompanied by other disorders. About 90% of people with anorexia nervosa or bulimia nervosa have one or more comorbid disorders, such as depression, anxiety disorders and drug use disorders.
Development process
Anorexia often develops in adolescence, with peaks at the age of 14 and 18. Sometimes it is about one period, while the disorder keeps coming back to others. Still others arrive but continue to display disturbed eating behaviour that meets the criteria for bulimia nervosa or EDNOS. The prognosis appears to be better for adolescents than adult women with anorexia nervosa. Extreme weight loss can lead to medical complications such as hormonal changes and loss of bone density, and the disorder can be life threatening.
BN often develops from adolescence to early adulthood with a peak period of 14 to 19 years. Binge eating often occurs during or after a period of dieting. There is serious dissatisfaction with body weight. Bulimia nervosa can be chronic or interrupted, with recurring episodes of bulimia nervosa. However, in the long term the symptoms usually alleviate. Although some may no longer meet the diagnostic criteria for bulimia nervosa, problems may persist, and someone may meet the criteria for EDNOS. Many also meet the criteria of depression. The repeated vomiting associated with bulimia nervosa can lead to problems with the teeth and other medical problems, such as irritation of the oesophagus.
Aetiology
Biological influences
Research has suggested that prenatal exposure to low testosterone and high levels of oestrogen is associated with eating disorders. In addition, anorexia nervosa often develops around puberty. Possibly, hormonal changes in puberty moderate genetic influences on disturbed eating behaviour.
Research has also been done on neurobiological and genetic influences. Eating behaviour can be influenced as well as have consequences for neurobiological and neuroendocrine systems, making it difficult to draw conclusions about causal relationships. Research suggests that differences in the activity of neurotransmitters play a role in eating disorders. For example, serotonin plays a major role in the inhibition of food. People with anorexia nervosa and bulimia nervosa have too little serotonin. There is also evidence for a genetic contribution to eating disorders.
Early eating problems
Early eating problems increase the risk of anorexia nervosa and bulimia nervosa. Many people with eating disorders have eating problems at a young age. Research shows that pica is a risk factor for bulimia nervosa and that eating choices are a protective factor. Pickiness, on the other hand, is a risk factor for anorexia nervosa.
Weight history
The history of the weight of both the individual and the family are considered as a possible risk factor for eating disorders. For example, a family history of being overweight is a risk factor for bulimia nervosa.
Temperament or personality traits
The temperament quality of negative affectivity is associated with disturbed eating behaviour and disturbed attitudes. However, this quality is a non-specific risk factor, because it also increases the chance of other disorders, such as anxiety and depression. However, the relationship between personality traits and eating disorders remains unclear. Possibly personality traits influence the course of an eating disorder or are the consequences of an eating disorder.
Sexual abuse
There is a small connection between sexual abuse and eating disorders. However, the nature of this connection is unclear. For example, sexual abuse appears to be a risk factor for psychopathology in general rather than specifically for the development of eating disorders.
Cultural influences and body dissatisfaction
Cultural factors also influence the development of eating disorders. In the west, a thin body is the ideal of beauty. This probably contributes to body dissatisfaction and the development of eating disorders. Body dissatisfaction can also lead to low self-esteem and depressive symptoms, which can contribute to the development of eating disorders.
Family influences
Finally, family factors play a role in the development of eating disorders, such as attitudes and ideas of parents towards food, weight and body shape. Little contact with parents and high expectations of parents are risk factors for eating disorders. The families of young women with eating disorders are often characterized by conflicts between parents, rejection of indifference, controlling behaviour and overprotective behaviour. However, it is difficult to determine whether family characteristics are a cause or consequence of an eating disorder.
It is also important to remember that family could be an important factor in the treatment of this disorder. This could be prevented by blaming.
Family treatment
The development of family treatments for eating disorders is derived from the fact that families are often involved in maintaining behaviour. There is limited evidence of the effectiveness of family interventions in treating adolescents with anorexia nervosa. A distinction can be made between two types of family treatments for anorexia nervosa:
Cognitive behavioural therapy
Cognitive behavioural therapy is seen by many as the most effective form of treatment for bulimia nervosa. However, this evidence is largely based on samples taken with adults, which may make the evidence not representative of other groups: in this case, mainly adolescents. Cognitive behavioural therapy is based on the assumption that eating disorder is maintained by a dysfunctional schedule for self-assessment (with too much emphasis on body shape and body weight). According to cognitive behavioural therapy, cognitions about body weight and body shape are the primary characteristics of bulimia nervosa. Other features, such as dieting and vomiting, are seen as secondary features.
At the start of treatment, the person in question is informed about bulimia nervosa and associated cognitions. Behavioural techniques are used to reduce binge eating and compensatory behaviour and to increase control overeating patterns. These techniques are supplemented with cognitive restructuring techniques. As treatment progresses, the emphasis is increasingly being placed on incorrect cognitions and improving self-control strategies to withstand binge eating. Finally, the focus is on strategies for maintaining behavioural improvements and preventing a relapse.
Interpersonal psychotherapy
Interpersonal psychotherapy (IPT) focuses on the interpersonal problems involved in the development and maintenance of an eating disorder. This form of treatment therefore does not primarily focus on eating symptoms, but on improving interpersonal functioning and communication skills. This is done because research shows that interpersonal factors (such as comparison with others) influence body image and self-confidence. The focus of interpersonal psychotherapy can be on one or more of the following four interpersonal problem areas: interpersonal deficits, interpersonal role issues, role transitions and mourning.
Pharmacological treatment
There is little evidence for the effectiveness of pharmacological treatments for anorexia nervosa. Adult studies show that SSRIs or other antidepressants are effective in treating bulimia nervosa. However, the role of medication in the treatment of bulimia nervosa in adolescence remains unclear.
Prevention
There are several types of programs for the prevention of eating disorders. Some programs focus purely on weight regulation such as Healthy Weight Regulation (HWR), others focus more on social competence and self-confidence such as Self-esteem and social competence (SESC). Positive outcomes have been found for the SESC program at school age. No clear effects of the HWR approach have been discovered. Evidence has been found that interventions reduce risk in high risk individuals in the short term. Whether this effect can be generalized to all adolescents or children remains to be seen.
can be generalized to all adolescents or children remains to be seen.
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