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03/28/16 Lecture 1

04/04/16 Lecture 2
Defining Health, Illness, and Well-Being
 “A state of complete physical, mental, and social well-being, and
not merely the absence of disease or infirmity.” – WHO, 1948
 To have positive well-being, children require:
o Loving families
o Friends
o A positive lifestyle
o Solid values which give meaning to life
o Good schools
o Good mental health
o Enough money to live without shame
 These psychosocial factors also translate to positive
health outcomes
Health and Illness
 two ends of a spectrum
health  Illness
… or overlapping constructs?
Children’s Understanding of health and illness
 Myrant & Williams (2005)
o Differences between definitions of “health” and “illness”
and changes with age
o Younger ages vs older adolescents: younger don’t really
know; as older, can see the difference between health and
Stress and Wellness
 Stress: the condition that results when person-environment
transactions lead the individual to perceive a discrepancy
(whether real or not) between the demands of a situation and
the resources of a person’s biological, psychological, or social
o Ex: school – not having the time or energy to study
o Social systems – having someone there to give you support
The process of cognitive appraisal of stress

We initially assess the meaning of a potential stressor (primary
o Ex: boss giving you a project
Then, we decide if the event or situation is stressful, and in what
o Can see it as a threat/potential future harm (ex: not
finishing job = getting fired)
o A challenge – being able to accomplish it (ex: finishing the
job = getting a promotion!)
o Harm loss – damage has already been done (ex: dropping
your phone)
Secondary appraisal (same time as primary) evaluation of an
individual’s ability to cope and resources available to do so

Coping Styles
 Problem-focused
o Fixing/attacking the problem
o Can’t always be done (ex: bringing back someone who’s
passed away; fixing a relationship)
 Emotion-focused
o More about emotional disclosure
o Processing the emotions
o Revealing and examining the emotions
o Changing ones’ emotional response to something
o Ex: journaling, distracting, meditating
o Works when the situation is like when someone’s passed
o Doesn’t work if the situation is like paying the bills
 Meaning-focused
o Drawing on one’s own beliefs and values
o Getting some meaning or purpose from it
o Ex: taking care of a loved one who’s passing away – can be
difficult to deal with the loss – can focus on taking care of
the person, but can’t prevent them from passing away
o Attaching meaning to something – giving meaning to
 Ex: in someone’s final days, you’re able to give
meaning and love to something
 It is the meaning of the event, not the event itself, which defines
if it is stressful

o Ex: kids experiencing parental divorce – can view it as bad
(not wanting them to separate) or good (parents will be
happier this way)
Major life events – long lasting events
o Ex: death in a family, serious hospitalization, moving
Minor life events – not long lasting, but still requires recovery
o Ex: parents experiencing income decrease or job loss,
failure at school
Daily hassles – things that effect you, but in a short term – can
happen frequently throughout the day
o Ex: traffic, losing things, being late, arguing with someone,
public speaking, being teased, getting in trouble

**how are children stressors different from adult stressors**

Perceived stress – “the weight of the world on your shoulders”;
the demands creating a burden on your life
Control and tolerance
o “eustress” and “distress”
o not being able to tolerate something  distress
o being able to tolerate something  eustress
 procrastinating
Importance of coping – kids need to experience stress in order to
learn how to cope
o Parents trying to prevent kids from feeling stress (keeping
them from waiting, giving them everything, making sure
they are well equipped, kids always having electronics, etc)
Acute – short-lived
o Problems at school, problems at home, performing a
speech, doing a math problem
o Extreme acute = terrorist attacks, natural disasters,
Chronic – long-term consequences
o Loss of a loved one, abuse or maltreatment, parent
Modern – new stressors that we’re not equipped to deal with
o Parent losing job, divorce, moving homes – idea of
Ancient – old stressors that we should be equipped to deal with
o Child being upset by family arguments, having to deal with
people whose behavior is frightening – idea of being
together but having conflict due to behavior

o Kids are better able to cope with ancient stressors than
modern stressors
Developmental levels of the understanding of illness (Bibace & Walsh,
 Magical Level (association) -- symptoms
o Phenomenism – a cold when you have a runny nose
o Contagion – going out in the cold during the winter
 Concrete Level (sequence)
o Contamination – illness in terms of symptoms and the
cause originating from an external factor – a cold when you
stay in the cold water
o Internalization –
 Abstract (interaction)
o Physiological - a runny nose and cough caused by germs –
your body reacting to a virus
o Psychophysiological – catching a cold when you haven’t
slept/when you’re stressed
Children’s understanding of health (Normandeau et al., 1998)
 Children age 5-12 years show complex understanding of health,
comprised of:
o Functionality
o Mental health
o Life-style health behaviors -- hygiene
 No sex differences
Children’s understanding differs by illness type (Myrant & Williams,
 Better understanding of the cause of a toothache than asthma or
a cold
 Despite personal experiences with colds, they have more
misunderstanding than other illnesses
o However, they had knowledge regarding prevention and
recovery regarding the common cold
o Where do children learn misinformation??
 Making connections from previous information
How can psychosocial factors influence physical health?
 Modern psychological stressors are typically not life-threatening,
but still result in the same physiological response
Life-threatening situation  stress  physiological response 
immune change and disease susceptibility

Ex: fight or flight
Lutgendorf & Costanzo (2003)
Biological Responses to Stress
 Dual system
o Sympathetic adrenomedullary (SAM) system
 Produces epinephrine and norepinephrine
(adrenaline and noradrenaline)
o Hypothalamic-pituitary-adrenal (HPA) axis
 Produces glucocorticoids (ex: cortisol)
 Cortisol helps us deal with stress by shutting down
unnecessary functions, like reproduction and
immune system, so the body can direct all energy
toward dealing with the stress
**This is how stress effects not only the biological system, but
the immune system
 24-hr circadian pattern
 12pm (high)  6pm (low)  12am (low)  6am (starts to
increase)  12pm (high)
Newborns and the stress response
 Two 12-hr intervals rather than morning peak of cortisol until ~ 3
 Infants who stress reactivity and habituation to stressors
 Ex: heel prick
o Healthy babies adapt to a stressor (high stress then
decreased stress as the pricks continue)
o Unhealthy babies are the opposite of this
Stress reactivity in older infants and children
 Attachment anxiety is a great source of stress
o Alleviated by good quality child care and adult involvement
in play
 Stress reactivity is not simply correlated with crying or visible
distress, they may also be attempting to cope
 Cortisol may be a barometer of the immune coping process
Cortisol Awakening Response (CAR)
 Preparation for daily stressors
 Emerges approx. late childhood or adolescence

and over-activity of Th2 is related to asthma. These conditions are not likely to co-occur. leading to a major mindbody influence Over. negatively impacting health . (if one is high. 1976): Emphasized adaptability of the stress response.   Affected by stress levels of the previous day(s) and anticipation of events Disruption caused by: o Persistent stress o Repeated or severe stress o Psychosocial resources are not available o Alteration of night and day activity levels Cortisol primary suppresses immunity. the other would be low) Psychobiological Theories of Stress and Coping  William James (1884): emotions follow behavior  Walter Cannon (1929): fight or flight theory of stress response and role of hormones  Selye (1956. Stages: o Alarm o Resistance – body copes physiologically by producing hormones o Exhaustion: the body runs out of stress hormones.and under-production of cortisol in childhood  Over-production (stress response or infection) can lead to growth retardation o Cushing’s disease  Under-production can lead to immune over-activity and autoimmune disorders o Addison’s disease The Immune system  Bone marrow produces two types of white blood cells (leukocytes) o Lymphocytes (T cells and B cells (antibodies)) o Phagocytes (cells which engulf bodily invaders (antigens))  The immune system is complex o The immune system o The balance of T-helper cells  Over-activity of Th1 immune response is related to type 1 diabetes.

having a high activity over a longer period of time and no recovery  Inadequate response . extremes of temperature.having low to no activity Individual differences  Resiliency: a dynamic developmental process of encompassing the attainment of positive adaptation within the context of significant adversity o Personal qualities o Attributes of the family o Characteristics of the broader social environment Topic 3) Research Methods and Ethical Issues Ideal Research Approach Psychosocial input  physiological changes  health outcomes • Simultaneous study of all three concepts is the “gold standard. helplessness. physiological alterations necessitated by infection  Allostatic load: repeated lifetime stress (threat. but when they continue to be produced at a high rate over a prolonged period of time The stress response itself is damaging Allostasis and Allostatic Load  Allostasis: the body maintains stability (homeostasis) through change o We adapt to different physical states. cope with changing noise.  Robert Sapolsky (1994): Vulnerability to illness is not caused by stress hormones running out. vigilance) o Like a “fossil record” or your life experiences Types of Allostatic load  having a strong allostatic load/activity and then recovering to baseline level  Repeated trials(?) and lack of adaption – allostatic load o Having a constant repeated increase and decrease in activity over time  Prolonged response . overcrowding.” but is not always feasible .

we may rely on parent report via interview or questionnaires o Need to be age specific and understandable o Assessments need to be applicable to age levels and need to be understandable for parents Children’s Hassles Scale (Kanner.Measurement of Psychosocial Factors • Stress • Coping responses • Social support • Temperament • Family socioeconomic status • Etc. 1987) (Screenshot) Children’s Coping Questionnaire http://summit. • For younger Social Mapping: Five Field Map Immune Markers of Stress • In vitro (outside of the body) o Enumeration: counts of white blood cells o Functional to the response of cells to antigens in a sample • In vivo (inside of the body) o Delayed-type hypersensitivity: subcutaneous Social Support Questionnaire for Children http://etd. look for a reaction after a few days o Deliberate exposure (viral challenge) Neurotransmitter and Endocrine Markers of Stress • Originally via blood and urine.pdf The Coping with Cyberbullying Questionnaire http://www. but saliva testing is more common now.mdpi. especially for cortisol o Cotton swab in mouth for 1-3 minutes. may be flavored for children o Timing is important .lsu.

implemented as a randomized controlled trial (RCT) Health Outcomes: Acute Illness • Upper respiratory infection o Follow healthy children for 6 months. feeling faint or dizzy Health Outcomes: Chronic Illness • Functional ability • Pain • Quality of life • Survivorship Research Settings • Laboratory/experimental examples o Strange Situation: Separation from mother o Visual Cliff: Depth perception and social referencing o The Trier Social Stress Test for Children: Recite multiplication tables and create an ending to a story. missing the Cortisol Awakening Response • Attempting to get the child to give the sample can induce stress and artificially inflate cortisol levels Health Outcomes • Disease onset • Disease progression • Recovery or length of survival • Quality of life • Ultimate research: Intervention study. BBC TV show documenting the lives of 25 children born in 2000 for 20 years . duration. and intensity • Other minor symptoms: headache. track cold and flu onset. stomach ache.• Hair sample: retrospective assessment chronic stress of pregnant women Potential difficulties with salivary testing of children? Compliance in Salivary Cortisol Testing • Children may wake before the parent. present in front of a 3person panel • Naturalistic setting examples o Common cold and flu and other naturally occurring events o Self-administered saliva test o Interviews and questionnaires o Daily diaries o Child of Our Time.

1994 Informed Consent • Informed consent is the process of obtaining permission before administering tests or interventions. • Assurance of confidentiality is part of informed consent • Exception: when a participant indicates they may harm themselves or others • Anonymity may be best in some situations. but does not allow the researcher to refer for help or follow up Coercion • No pressure to participate is permitted o E. scores. Is this ethical? • Money should only be compensating for time or inconvenience Deception and Debriefing .youtube.g. https://www. videos) o Alternative treatments o How the data will be used o Potential risks. such as the right to stop at any time • Legal guardians provide consent for participation for children birth-17 years • Children age 7+ also provide informed assent Ethical concerns? **children can’t give consent because they’re too young to understand ex: a kid made fun of a kid for stuttering  made fun of kids who didn’t have a stutter and ex: those kids eventually developed stutters ex: testing vaccinations ex: hermaphrodites/sex changes Confidentiality • Personal information should not be shared or leaked o Is this ethical?? Ethical Issues “The history of pediatric experimentation is largely one of child abuse” Lederer & Grodin.. address. Requires informing research participants of: o Procedures (tests. video. etc. surveys. such as asking about drug use or sexual behavior. including breach of confidentiality o Potential benefits o Individual rights. no threat of punishment o Parents are often given a gift card or small cash amount for their children’s participation.

kept to a minimum.” immune to harmful environmental toxins present in the mother • Periods of prenatal development o Germinal (zygote or blastocyst): first two weeks after conception o Embryonic (embryo): weeks 2-8. organ formation o Fetal (fetus): Weeks 9-birth  Trimesters o First: weeks 1-12 o Second: weeks 13-27 o Third: weeks 28-40 Importance of the Placenta • Develops during the Embryonic Period o Transports oxygen and nutrients from the mother’s bloodstream to the embryo/fetus o Transports carbon dioxide and metabolic waste away from the embryo/fetus to the mother’s bloodstream • Placental barrier: semi-permeable membrane provides protection from some toxins during development **What can get past the placental barrier?? o Medication o Drugs o Alcohol o Some infectious diseases o Mercury o • Teratogens: environmental agent that has a negative effect on the developing embryo/fetus o Can stress be a teratogen? Yes! The normal basal maternal endocrine environment during pregnancy . avoided if harmful. followed by debriefing • Debriefing: correcting misinformation and revealing study goals • Can deception without debriefing be justified in some cases? 04/11/16 Lecture 3 The Influence of Prenatal Exposure to Stress Pregnancy and Prenatal Development • The fetus was once believed to be a “perfect parasite.• Deception: withholding information o Must be carefully considered. placenta develops.

g.. babies having a preference for carrots because mothers eat carrots during prenatal period)  Voices. motor movement) -.e.g. increased fetal heart-rate) • Reduced fetal responsiveness to novel stimuli if mother had higher placental corticotrophin releasing hormone (CRH) in 3rd trimester • Is this prenatal programming of the developing nervous system? • When does parenting begin? o Other examples of fetal learning  Taste preferences (babies can develop preferences based on mothers’ habits – i. but physiological reactivity to stress is diminished during pregnancy o Blood pressure o Heart rate o Cortisol • Little attention has been given to speed of recovery or habituation Effects of Prenatal Stress in utero • Fetal hyperactivity (e. rhymes.agitation • Cardiovascular responses (e.• Pregnancy is a “transient period of relative hypercortisolism” • Cortisol levels peak two to three times non-pregnant levels during the third trimester and the adrenal glands enlarge due to the increased demands • The progressive increase in hormones of the HPA axis (CRH.. cortisol) and endorphins throughout pregnancy culminate in labor and delivery The Stress Response During Pregnancy • Basal levels are high. ACTH. music (playing music and talking to the womb so that baby can become familiarized with sounds) Effects of Prenatal Stress on Birth Outcome o Human studies have linked stress during pregnancy to: o premature birth (before 37 weeks) o being small for gestational age o having a low birth weight • Consequences of preterm birth o Increased infant mortality o Infant health problems o Long-term intellectual and developmental disability o Lifetime physical and psychological illness .

ear malformations) especially if exposure was during first trimester • Results are not always consistent o 9/11 attacks: Post-traumatic stress symptoms linked to longer gestation..g. but amplified in the fetus • Increased stress hormones influence birth outcome o Rise in corticotrophin releasing hormone (CRH) is essential to bring about labor and delivery. 2009: 13. 2008) o Loss of a close relative during pregnancy and up to 6 months before conception o Reduced birth weight for babies whose mothers experienced a loss peri-conceptionally or during any of the three trimesters o Impact of stress on fetal growth was greatest of exposure was in the second trimester • Natural and human disasters have a greater impact on fetal growth rather than on gestational age o Hurricane Katrina o Earthquakes o Terrorist attacks • Tan et al. but smaller head circumference (Mulherin Engel et al. 2011) o 2.38 million mothers (Khashan et al.• Preterm birth rate in US (2013) at 15 year low of 11.000 newborns born before and after Wenchuan earthquake o Reduced birth weight o Poorer Apgar scores (reactions to stimuli – crying/grimacing when pinched) o More birth defects (e.6 million births between 1973-2004 o Identified whether or not death of father or immediate relative was experienced during pregnancy o Conclusion: during months 5 and 6 of pregnancy (2nd trimester).5% o Can be related to effects of medical care Effects of Prenatal Stress on Birth Outcome • Swedish study using population registries (Class et al. life-event stress has the greatest impact on preterm birth or reduced size • Danish study of 1. too early. but if levels increase too rapidly.... then it can induce premature delivery • Pregnancy is a state of heightened physiological balance or allostasis with the potential for allostatic load consequences (birth outcome) .. 2005) The Role of CRH and Cortisol • Stress reactivity is dulled in the mother.

of skin. but this may be reduced in times of high stress o Impaired or abnormal blood flow within the uterus Effects of Prenatal Stress on Infant and Child Development  Most studies have found negative effects of stress on behavioral.• Most studies confirm that the 2nd trimester is a crucial time for stress exposure influencing birth outcomes • Ellman et al. and temperamental outcomes o i.. genitalia) o Higher cortisol levels at 15. poor recovery from stimuli.g. and 25 weeks (2nd trimester) and CRH at 31 weeks (3rd trimester) were associated with poorer maturational outcomes in males • Entringer et al...g. (2011) o Higher cortisol levels during pregnancy associated with lower birth weight and length (height) o Self-reported levels of stress and perceived stress during pregnancy were not related to cortisol levels or birth outcomes  Self-reports of stress are not better predictors of outcomes How does maternal stress transmit across the placenta to influence prenatal development?  Two possibilities (Van den Bergh. 2005) o Hormone transfer across the placenta: high levels of stress hormones in the mother directly influences the fetus via exposure in the uterus  The placenta restricts transfer of glucocorticoids. ears. eyes. 19.e. cognitive. etc. 2008: maternal stress hormones in the blood and newborn neuromuscular (e. some indication that mild stress is beneficial . (2011): o Shorter length of gestation (pregnancy) associated with:  Higher level of cortisol at awakening  A smaller Cortisol Awakening Response (CAR)  Greater cortisol across the day o Negative affect was recorded via mobile devices  Associated with higher diurnal cortisol. (1009): Infants whose mothers had experienced high perinatal and lifetime trauma were slower to recover from the increased behavioral and cardiorespiratory responses induced during lab stressor  However.  Bosquet Enlow et al. but not gestational length  Subjective mood may not be a good predictor of birth outcome • Bolton et al. anger. mental temperament. muscle tone and flexibility) and physical maturation (e.

yet flattened. (2011): mid-pregnancy stress and depressive feelings associated with less infant crying and fussing at 3 and 5 months. Individuals in utero:  First trimester: normal size. diabetes. David Barker’s Hypothesis (1986): the poorest areas of England were the same areas with the highest rates of heart disease. obesity  Second trimester: higher risk of cardiovascular disease  Third trimester: born small and stayed small their entire lives. o Prenatal nutrition and low birth weight  heart disease? o Fetuses learn to adapt to the environment they expect to live in o Low availability of nutrients during prenatal stage followed by improvement in nutritional availability in early childhood causes increased risk of metabolic disorders.o Rothenberger et al. For girls. this changes – baby is well fed  can cause metabolic disorders like diabetes • The Hunger Winter o Nazi barricade during WWII led to severe famine in The Netherlands. diurnal cortisol profile in children. such as Type 2 diabetes  poor nutrition during prenatal period sets fetus up to think this will be the circumstances it will have when it’s born  but then when born. no obesity or disease o These changes create a “tag” on DNA that can be passed down: “epigenetics” . but with high blood pressure. this profile was related to depressive symptoms o Wust et al. Not related to cortisol. Effects of Prenatal Stress on Adolescence (11 years) and Adulthood • Very few studies… why?? • Effects on cortisol o O’Connor et al. (2005) Low birth weight was related to greater salivary cortisol response to Trier Social Stress Test during young adulthood  Prenatal stress or anxiety has a longitudinal effect on altered HPA axis functioning to adolescence Fetal Origins of Disease Hypothesis o Environmental conditions during prenatal development impact developmental health and wellbeing for life o Dr. (2005): Anxiety at 32 weeks associated with reduced Cortisol Awakening Response in pre-adolescence o Van den Bergh (2008) association between pregnancy anxieties experienced between 12 and 22 weeks and a high.

poor listening • Nervous habits like nail biting. or anxiety (mood changes) • Becoming withdrawn • Behavior problems. size. panic. tummy aches. or neck pain (physical aches) • Increased irritability. genes that were silenced grew to be brown and thinner  Epigenetics – signals your cells and genes to be active or silent o Ex: emotions. crying. thumb sucking • Overreacting to problems • Unusually low energy or high energy and restlessness Causes of Stress • Life changes • Problems with peers: being bullied. hair twisting. etc – can effect children as well Topic 5) The Experience of Stress During Childhood Signs of Stress in Children • Trouble eating. anger. such as biting. feeling different. whining. DNA is not destiny: http://www. higher heart disease rate. job losses. working and financial stability. social isolation • Feeling unliked or unloved • Conflict with others • Schedules that are too busy • Problems with school work • Should parents protect children from all stressors? . impulsiveness. sadness. color  Mice that were given BPA – found in plastic – offspring had greater defects.  Stressful environment led to low licking mother – mom mice couldn’t tend to her offspring very well because of the lowresource environment she was in  Growing stressors = low finances. more health issues. bigger and obese. relaxing. or sleeping (daily activities) • Increased clinginess. etc. or fighting (emotional stems) • Recurring headaches.raisingofamerica. acting out. anxiety. VIDEO:  Genes that are expressed or silenced can effect your development/formation o Mice experiment – genetic makeup was altered  Genes that were expressed grew to be yellow and bigger.

. involves social evaluation and novel social and physical challenges • Cortisol levels may increase in the 6 months before school begins in anticipation. but children who were physiologically more reactive showed higher rates of illness if in a high-stress environment **Just because it was reported doesn’t mean it was actually true o Low-reactivity children did not show higher rates of illness even in a high-stress environment – didn’t matter what environment . especially for those who were socially isolated • Prenatal stress exposure predicts cortisol reactivity in 5-year-old children • Beginning school may provide a point of assessment for accumulated life stress Stress Reactivity and the Common Cold (Boyce et al.Normal Response to Stress in Healthy Children • Naturally occurring stressors for children in developed countries o Childcare/daycare/preschool o The transition to school (kindergarten) • Increase in stress hormones is a natural response to these new experiences and challenges • Ideal response is reactivity  adaptability (stress levels going down over time) Quality of Childcare • Low quality in-home or out of home childcare associated with increases of cortisol from morning to evening • Combination of low-quality childcare and child temperaments of negative affectivity and lower effortful control has been associated with increased cortisol throughout the day • Having attended a large-group day care to 3 years old is associated with higher risk of having a cold in 2nd year of life. and adaptively decline 6 months later • Children with more extroverted or impulsive temperaments tend to have higher cortisol levels. rise with the start of school. 1995) • Measured: o Childcare-related hassle stress and stressful life events o Cardiovascular and immune reactivity – physiological responses o Symptoms of respiratory infection • There was no direct link between stress and illness. but then increased immunity at age 6-11 years The Transition to School • Social stressor for typically developing children.

such as frequent smacking or maternal emotional withdrawal may be associated with increased basal cortisol and cortisol reactivity • Children with clinically depressed mothers have shown disruptions in circadian cortisol o Spaceship study: anxious and withdrawn children with a history of depression in the mother was associated with elevated cortisol levels  Puffs of air were puffed at the kids to get a reaction o Intergenerational transmission of psychopathology?  Done to see if stress in mothers transmitted to their kids • Adults with PTSD show inadequate response. the experience of childcare was beneficial in preventing hypercortisol responses Health in Adulthood and Across the Lifespan • Childhood maltreatment affects physical health as much as it affects psychological health • Roy et put them in. childhood trauma was related to an elevated cortisol response. malnourishment = toxic stressors • Even subtle forms of child maltreatment. (2011): The experience of multiple . neglect. indicating an intergenerational transmission of the low-cortisol response profile seen in PTSD o Even though the kids didn’t experience the holocaust. characterizing a pattern of allostatic load • Children show higher levels of cortisol in response to maltreatment or abuse o Precursor to adult pattern? Family Environment and Intergenerational Transmission of Stress • Yehuda et al. which may influence the onset and severity of the condition • Kiecolt-Glaser et al. (2005): for children with high family stress. the stress didn’t translate to them getting a cold o Lowest illness rates for high reactivity children in low stress environment **high reactivity and high stress led to high rates of illness Effects of Severe or Toxic Stress (PTSD) **poverty. (2010): In a sample of adults with fibromyalgia or osteoarthritis. they still had low cortisol • Cryssanthopoulou et al. (2001) found low cortisol in adult children of Holocaust survivors. (2010): Child abuse is associated with an increased risk for coronary heart disease • Nicolson et al.

adversities during childhood was associated with reduction in telomere length and was projected to reduce lifespan by 7-15 years. but 86% of children say it does o There may be a lack of communication and teaching children how to recognize and cope with stress o Kids don’t know how to communicate what they’re feeling  therefore they’re not a good measure of stress o Also. Communicating Stress • Common finding: disparity between the experienced. shortness of breath. parents don’t recognize when their kids experience stress • Biological responses may be a more definitive way to measure stress and it’s short.and long-term outcomes New Modern Stressors? • Busy schedules and lack of free play? • Lost Adventures of Childhood: https://www. restlessness. and/or chest tightness  Severe attack: inability to speak. sound of v=qLF0q-KlWT0&index=1&list=FLmYHVpI7AzqBwwt9SdEiA8g o Why are kids not playing as much outdoors/in their neighborhood?  Preventing kids from playing outside can cause stress on children (stress from confusion. exhaustion. perceived stress and physiological level of stress (cortisol). blue skin Prevalence and Etiology • Approx. 69% say their stress doesn’t affect their child. stress from needing to be watched every moment. wheezing. Why?? • Parents may not recognize stress in children. 7 million children affected (See Chart) • Girls more affected than boys . stress from having a structured schedule – not playing outside because they have other things to tend to like soccer practice or piano practice. called bronchial tubes • Certain triggers can cause swelling and tightening of bronchial tubes and muscles around them • Coughing. etc) 04/18/16 Lecture 4 Childhood Asthma What is Asthma? • Chronic disease involving inflammation of airways into the lungs.

they were less likely to grow up to develop asthma ** allowing them to be exposed at a young age means that their immune system is able to develop more strongly **before adolescence – asthma is more prevalent in males (more narrow airways) **after adolescence – asthma is more prevalent in girls and females  puberty makes the body develop more  females are around more triggers (perfume. dry air or weather changes • Acid reflux and heartburn • Alcohol • Emotional anxiety and stress Asthma Management • Children must be aware of what their body is trying to tell them before an attack ensues • Identify symptoms • Know what to do in case of an attack • Recognize asthma triggers and how to avoid them • Keep physically active in spite of physical restrictions Asthma Action Plan • http://www.g.62 **if kids were more exposed to factors that triggered asthma at a young age. body sprays. beta-blockers) • Viral and bacterial infections • Exposure to cold.. aspirin. ibuprofen. etc) Diagnosis and Assessment • Medical history • Tests of lung performance. such as spirometry • Allergy testing – should know what you’re allergic to to avoid triggering your allergies/asthma Common Asthma Triggers • Allergies (including food and pet allergies): Exaggerated response of the immune system to foreign substances or allergens • Exercise • Tobacco smoke • Air pollution • Strong odors or fumes • Medications (e.• Genetic and environmental factors play a role o Heritability estimate: %20Documents/Libraries/NEW-WEBSITE-LOGO-asthma-action- .

allergy medications • For serious cases of asthma. including having to live differently to avoid triggers Psychosocial Issues • Weil et al. work & school • Limitations and independence • Missed work or missed school • Fear of fatality – fear of death over the duration because of shortage of breath – panic • Adequate resources. both fast-acting and long-term control meds are often utilized Issues or Concerns for Pediatric Asthmatic Patient and/or Caregiver • Compliance • Knowing how to deal with an asthma attack or related emergency • Communication w/ family.pdf Asthma Medications • Fast-acting o Temporary relief of symptoms by relaxing muscles around airways and allowing them to open up o May pre-medicate before exercise o Inhalers or nebulizers  Albuterol. Spiriva 1 Long-term control • Taken daily to control airway inflammation and treat symptoms • Several types: Inhaled corticosteroids (Flovent). mast cell stabilizers. (1999) study of inner-city children with asthma at 7 locations o Children with caretakers with mental health problems were hospitalized at twice the rate o Children with behavior problems had significantly more days of . theophylline. such as housing and finances Compliance • What is compliance? o Taking medications as prescribed o Following Asthma Action Plan • Reasons for non-compliance o Side effects of medications o Forgetting o Thoughts or feelings regarding normalcy. leukotriene modifiers (Singulair). Advair). Atrovent.plan_HI. longacting beta-agonists (Symbicort. injectable antibody that blocks allergic inflammation (Xolair).

suicidal ideation  Low self-esteem  Withdrawal from normal activities  Excluded from team sports o Obtaining goals. such as scoring a touch down o Feeling like a member of a team o Developing life-long friendships • Conflict with parents and difficulty establishing autonomy Behavioral • o o o o • • and Academic Effects Drop in school attendance Doctors’ visits ER visits Symptoms Environmental Triggers Physical education grades Falling behind due to poor attendance Interventions • Most common misconception is the amount and type of exercise that is safe • Exercise increases the lung’s capacity.wheeze and poor functional status • Stauenmayer (1981) o The amount of debilitation/body weakening experienced by children was related to:  Parental anxiety  Father’s perceptions of manipulation – dads perceive their kids as using their illness/issue to their advantage  Mothers self-perceptions of overprotectiveness (which may be related to mothers’ failure to acknowledge children’s manipulations) Behavioral and Emotional Effects  Anxiety. and self-esteem • Communication with family. which can exacerbate symptoms  Behavioral and Emotional Effects  Depression and loneliness. and is a proven way to manage asthma • Enroll parents and children in programs focusing on asthma management techniques and education • Asthma camps promote exercise. and others o “Just sit down and breathe!” • Trigger reduction in the home and at family gatherings • Balance of providing time and positive attention to the child with . friends. self-worth.

    asthma. – looking for consistency with the treatment regimen  Pets and smoking are the main factors o Families keep pets even though a family member has asthma because of their connection to their pets o Adults often have smoking habits that are too addictive to quit .  Fear triggered during shortage of breath  Having to take medications routinely – skipping treatments can cause continuation of inflammation Psychosocial factors that impact asthma Psychosocial consequences of asthma Assessment and intervention  Assessment and evaluations from psychologist/physician needs to be very detailed and in depth so patients understand what they need to do  Need to see what the families/patients are saying regarding medication – “sometimes we forget…” etc. take notes regarding: Challenges faced by children with asthma and their families  Asthma management – esp. etc. what’s their schedule. revolving around the families – what’s the family’s surroundings like. as well as to the other children in the home • School Environment o Teachers & staff o Medication access o Asthma action plan • Dealing with limitations and expression of feelings • Continued counseling and support groups for difficulty adjusting • Movement and exercise • Behavioral therapy o Reward systems o Relaxation techniques – relaxation/musical exercises. imagery o Systematic desensitization Cognitive therapy Problem-solving Family therapy Breathing retraining and biofeedback Video • APA: Childhood Asthma • While you are viewing.

measles. and then communicate to them about the illness on their level of understanding Parents: Concern and Medication Use • Andre (2007) o Parents show significant and sometimes inappropriate demand for antibiotics o Parents who had incorrect beliefs regarding antibiotics and worry about infectious illness were more likely to have antibiotics prescribed . leukemia – certain forms since it can be treatable. meningitis.MIDTERM 04/25/16 05/02/16 Lecture 7) Acute Illness in Childhood What is Acute Illness?  Lasts for a relatively short duration of time  Sudden in onset • Symptoms change or worsen rapidly • May involve only one physical system or part of the body • Can be mild to severe or terminal • Can lead to chronic symptoms and conditions (e. cold and flu. Children’s Understanding of Acute Illness • Children’s causal attributions are important and may involve acceptance and/or self-blame • How to speak with children about acute illness -. pain and disability) **chicken pox. neglect of other children.need to assess children’s understanding of their illness. strep throat (if left untreated. needing to be a caregiver. can lead to life long problems) Acute Illness • Being ill is a stressor itself o Diagnosis o Treatment o Follow-up o Unpredictability and uncontrollability o Fear of social evaluation o Threat to everyday functioning o Fear of death • Illness of the child affects the entire family o Financial problems. constantly being worried and stressed.g..

it was reported that approx. 300 children had died in the previous 25 years because parents refused medical treatment on religious grounds • Woman disabled after “faith healing” parents refused treatment (8 minutes): https://www. vaccinations • Influenced by: o Need for information o Talking to others o Feelings of control over the process o Cultural values and religious beliefs How much power should parents have over children’s medical care? • In • Case Discussions o Parents denied daughter of treatment due to religious beliefs – parents turned to prayer. then maybe can look into alternatives instead Symptoms without a Detectable Cause • Influenced by: o Excessive parental concern and preoccupation with child symptoms o High parental health anxieties Coping with Acute Illness • Coping: Conscious volitional efforts to regulate emotion. 1997) o Primary control coping: Action o Secondary control coping: Adaptation . medication. then yes. social) • Coping Subtypes (Compas et al. behavior. not doctors o Should there be restrictions of religious beliefs? What’s to stop people from doing other things due to “religious beliefs” o What about 1st amendment? Religious freedom? o Mandatory reporters – need to report any suspected abuse o How much control/consent should be given to parents?? CASES: * Spinal taps on children – lumbar puncture to diagnoses meningitis – what are the risks and benefits? If benefits > risks. cognition. physiology.o Parents with one child worried more about illness **misuse of antibiotics can cause resistance Parents’ Decisions Regarding Child Health • Examples: Screening. and the environment in response to stressful events or circumstances • Coping behaviors utilized are influenced by developmental level (biological. But if not.

Factual o Communicate practicalities about treatment and regimens only Fathers • May feel emotional shock and pain • Prefer problem-focused coping over emotion-focused coping • Often feel as though they are on the periphery. but parents who believed the diagnosis to be terminal communicated less • Movement from protectionist avoidance philosophy to open and honest communication o Children are able to adapt better if they are told more about the diagnosis and consequences early **information needs to be more age appropriate so children understand and can adapt better Parental Communication of Diagnosis and Treatment • 1. with mothers taking the primary role (maternal gate-keeping) o 2/3 of mothers assume responsibility for medication • Need to retain control and return back to normalcy History of Children’s Hospitalization • Before the advent of children’s hospitals in the 1850s. when they were restricted due to risk of infection and parental interference with care . Optimism o Communicate benefits of treatment only • 2.o Disengagement coping: Withdraw • Children are more likely to remain healthy under stress if they do not use avoidance as a coping style • Children report having contrasts of experiences Communicating the Diagnosis and Treatment to Children • How would you communicate various diagnoses to children? • What influences your decision to communicate some information. Pessimism o Communicate side effects of treatment only • 4. Realism o Communicate side effects of treatment plus benefits of treatment/hope • 3. but not all? • Parents who were shocked by a diagnosis communicated more information. children were rarely hospitalized • Paternal visitation was encouraged until the late 1800s.

but what stressors remain? 1 **being in an unfamiliar/uncomfortable environment. because parents can help with daily care. v=s14Q-_Bxc_U • It is now common for a parent to stay with their child in the hospital. infections • Although children are frequently if possible. a lot of chaos going on (monitoring. such as car accidents. Intensive Care Treatment (Colville. burns. rather than cured . etc) Children’s Fears and Concerns about Hospitalization (Coyne.• o o o Late 1800s through 1950s Restricted parent visiting hours Lack of a child-centered environment James Robertson’s films https://www. >1 year?)  Gradual onset and development  Worsens over time  Can involve multiple bodily systems  Can be mild to severe or terminal  Often managed. they frequently experience traumatic memories and hallucinations relating to their hospital experience • Some may develop clinical levels of anxiety and PTSD 8) Chronic Illness in Childhood What is Chronic Illness? • Persistent or recurring over an extended period of time o No exact time specified (>2 months. 2012) • Acute emergencies. lots of overwhelming factors – different nurses coming in and out. 2006) • Unable to make sense of the experience • Perceived lack of emotional involvement from staff • Separation from family and friends • Being in an unfamiliar environment • Receiving tests and treatments • Loss of self-determination and independence • Hospitalization stress can affect recovery rate Parental Involvement in Hospital Care • Reduces separation anxiety and fear • Cost effective for hospitals. parents should provide car at home. medical equipment. and social/emotional well-being • Hospital stay lengths should be kept to a minimum.

playing. and socialization o Regular activities. and utilizing resources o Communicating with family. games. and nutritional needs. chronic arthritis **can range from mild – severe **can be terminal Understanding of Illness • Check to be sure information is understood correctly by children AND parents • Carefully use metaphors Prevalence • o o • Rates of Chronic Illness Affected by changes in lifestyles and health behaviors. obesity. but also foster independence o Own emotional functioning and support of the child o Planning. music o Family life and friendships o Embarrassment and feelings of normalcy • Consider o Visibility of the chronic illness o The number and type of contexts in which it is apparent Parents’ (and Children’s) Responses to Illness • Kubler-Ross Model applies o Shock and denial o Anger o Bargaining o Depression o Acceptance Parental Stress in Response to a Child with a Chronic Illness • Parental tasks and difficulties o Understanding the illness and finding information o Helping with medical. doctors . Examples: Obesity Myopia “Nature Deficit Disorder”: Chronic illness with long-term consequences? Chronic Illness • Interrupts o Parental attachment o Learning. physical. such as sports. May involve frequent doctor’s visits and may impact social life and school attendance **HIV/AIDS. friends. preparing.

Chronic Illness: Infancy • Task: Developing a sense of trust and attachment • Potential effects of illness o Multiple caregivers and frequent separation o Deprived of consistent nurturing o Delayed attachment . guilt. identity vs. pain. May become a “hidden patient” o o o • Children’s Accumulative Stressors • Medical sources o Hospitalization. autonomy vs. 1998: Children with HIV show a decrease in positive social self-concept over time. friend) Developing routines and maintaining family traditions Normalcy Younger parents and parents of younger children report significantly higher levels of stress • Adaptation to illness may be more difficult for parents than for children if the illness is present from birth • Many families may sometimes be overwhelmed or experience instability • The parent with primary responsibility may need emotional and practical support. feeling like an outcast. recurring symptoms. rejection Children with HIV • Moss et al. tec. confusion. growth failure.Uncertain role (parent. threat of shortened life span • Psychosocial sources o Separation from close family members. caregiver. but psychosocial adjustment was within normal range o More adverse life events related to higher chance of death • Disclosure of diagnosis to others o When to disclose? o Keeping it a secret is associated with negative health outcomes immune profile) Supportive Interventions for Children with Chronic Illness (see chart on EEE) – Erickson’s Psychosocial Stages:  During different stages of childhood (the age they’re at). frequent blood draws. social isolation. mistrust. initiative vs. chronic illness can disrupt favorable outcomes due to crisis – and lead to instead unfavorable outcomes  Ex: trust vs. doubt.

and failure o Guilt – thinking the illness is a punishment .• Supportive interventions o Encourage consistent caregivers and care by parent in hospital or other care settings o Encourage frequent visits by parents o Help parents learn special needs of infant for them to feel competent Chronic Illness: Infancy • Task: Learn through sensorimotor experiences • Potential effects of illness o Increased exposure to painful experiences • Supportive interventions o Expose infant to pleasurable experiences through all senses Chronic Illness: Year 2 • Task: Develop autonomy • Potential effects of illness o Increased dependency on parent • Supportive interventions o Encourage independence in as many areas as possible Chronic Illness: Infancy and Early Childhood • Task: Master locomotor and language skills • Supportive interventions o Provide gross motor skill activity and modifications of toys or equipment o Give choices to allow for simple feeling of control o Institute age-appropriate discipline and limit setting o Recognize that negative and ritualistic behaviors are normal Chronic Illness: Ages 3-5 • Task: Develop initiative and purpose • Potential effects of illness o Limited opportunities for success and accomplishing simple tasks or mastering self-care skills • Supportive interventions o Encourage mastery of self-help skills o Provide age appropriate play o Encourage socialization Chronic Illness: Ages 3-5 • Task: Develop a sense of body and gender • Potential effects of illness o Awareness of body may center on pain. anxiety.

and other skills o Encourage increased responsibility for care and management of illness o Encourage age appropriate activities o Be alert to cues that signal readiness for information regarding sexuality and reproduction Animal Assisted Therapy • Effective for a variety of: o Illness and psychological problems o Populations . assertiveness. abilities. abilities. and special skills • Supportive interventions o Realize many difficulties the teen experiences are part of normal adolescence o Instruct on interpersonal and coping skills o Encourage socialization with peers o Instruct on decision making. and special needs Chronic Illness: Ages 6-puberty • Task: Form peer relationships • Potential effects of illness o Limited opportunities for socialization • Supportive interventions o Encourage socialization o Provide child with knowledge about condition Chronic Illness: Adolescence • Task: Develop Personal and Sexual Identity • Potential effects of illness o Increased sense of feeling different from peers o Less able to compete with peers in appearance.• Supportive interventions o Encourage relationships with same-gender and opposite—gender peers o Clarify that the cause of child’s illness or disability is not his/her fault Chronic Illness: Ages 6-puberty • Task: Develop a sense of accomplishment • Potential effects of illness o Limited opportunities to achieve and compete • Supportive interventions o Encourage school attendance o Educate teachers and classmates about child’s condition.

and cognitive development in children • Mechanism: social support and bonding. which is essential for growth. activity. and brain function Blood Glucose Level • As a result of insulin deficiency. wound healing. development of relationship 05/09/16 Lecture Childhood Diabetes Type 1 Diabetes • Occurs in about 1 in 500-600 children • Results from autoimmune destruction of pancreatic cells that produce insulin. leads to ketoacidosis o Acid in blood damages organs o Can be fatal Hypoglycemia: Symptoms . blood glucose levels often deviate from normal range.o Age groups o Settings • Improved social. resulting in permanent insulin deficiency • Insulin regulates glucose metabolism. resulting in… o Hyperglycemia (high blood glucose level)  Too much food  Too little insulin  Illness  Stress o Hypoglycemia (low blood glucose level)  Too little food  Too much insulin  Extra exercise Hyperglycemia: Symptoms  Extreme Thirst  Frequent Urination  Dry Skin  Hunger  Blurred Vision  Drowsiness  Nausea  Diabetic Coma  If untreated. emotional.

insulin injection)  Calculating carbs and fibers and how much insulin to compensate/correct  Collaborating with families experiencing the same issues  Collaborating and communicating with doctors **Varies depending on age – i. but can cause diabetic coma Complications Heart attack due to reduced blood flow to heart Stroke due to reduce blood flow to brain Diabetic retinopathy caused by broken blood vessels in eye (loss of vision) Diabetic nephropathy (kidney damage/failure) Neuropathy (nerve disease) can cause pain. loss of feeling Loss of circulation causing slow wound healing Diabetic foot ulcers Treatments • Treatment to manage blood glucose levels o Eat healthy foods  Too many carbohydrates raise blood glucose levels o Get exercise daily o Check and regulate blood glucose levels with medications (insulin) Diabetes Management • Medication adherence & health behaviors o Knowledge o Skills o Motivation  How much insulin to give themselves  Carrying around equipment (insulin pump vs.e.• • • • • • • • • • • • Long Term • • • • • • • Shaking Fast Heartbeat Sweating Anxiety Dizziness Hunger Impaired Vision Weakness Fatigue Headache Irritability Not likely to be fatal. 16 year old vs. 3 year old .

and in other social settings • Social pressure may negatively affect adherence Skills needed for good diabetes management: • Ability to appreciate future consequences • Impulse control .miami.psy. needs to keep better track of what you’re eating • Degree of perceived interference in daily life o Management requires adherence to multiple daily tasks at home.pdf o Problem of social desirability – changing your information to conform to society’s standards • Direct Observation o Meal-time Observation Schedule o Interaction Behavior Code (family interactions) • Technological Alternatives o Memory in blood glucose meter o Food and fitness tracking apps • Family measures of functioning o Diabetes Family Responsibility Questionnaire o Diabetes Family Conflict Scale The Psychology of Diabetes: Risk Factors • Adherence is related to family factors o Perceived nagging o Conflict o Ineffective communication • Stress and diabetes o Stress autoimmune functioning onset of diabetes o Affects adherence • Adolescents may be at higher risk of eating disorders. due in part to weight gain associated with the initiation of insulin treatment o Purposeful omission of insulin treatment (to prevent gaining weight) (sugar is being added to the blood – blood sugar – so the body doesn’t utilize the sugar – instead it’s just being stored  causes weight gain) (insulin also changes the water retention of your body) • To prevent weight school.Diabetes Assessment • Self-report instruments o Johnson’s 24-hour Recall Interview  Conducted separately with child/parent o Self-Care Inventory  Completion of 14 diabetes-related tasks  https://www.

yelling. warmth. encouragement. name-calling. and empathy o Reasonable goals appropriate for child’s maturity level o Gentle reminding o Assistance in diabetes tasks o Changing home environment o Balance with needs for autonomy  Gradual yielding of responsibility associated with increased selfconfidence and personal ownership of regimen  Communication o Instruction and guidance o Modeling o Behavioral Rehearsal o Feedback o Monitoring • Communication o Encourage members to talk directly to one another rather than using third parties o “I” statements o Decrease interruptions. “mind reading” o Improve non-verbal communication .• • • • • • These Aspects of • • • • • • Delay of gratification Consistent good judgment High degree of social skill finesse Great time management Sense of personal responsibility Good sense of self are all skills that kids are still developing normal development that make management challenging: Testing limits Increasing desire for independence Developing good judgment through trial and error Increased desire to fit in with social groups Struggles with identity development Sense of invulnerability How Psychologists Can Help: Working with the Child • Injection strategies • Blood sugar testing • Nutrition and exercise plans • Communicating with medical team • Handling high/low blood sugar levels How Psychologists Can Help: Family Factors • Supportive (but not “nagging”) parental involvement o Praise.

cdc.aspx  Prevalence of obesity has increased over the past 40 years. and gastro-esophageal reflux (i.aspx Immediate Health Consequences of Obesity • High blood pressure and high cholesterol. CDC) o Calculator: https://nccd. heartburn) . smiling How Psychologists Can Help: Coping with Stress 1 • Support from health care professionals o Encouraging. but not for all age groups. and has since leveled off (~17% of children and adolescents. on percentiles from CDC national surveys (~1960s and 1970s) o such as sleep apnea.. Eye contact. empathetic. fidgeting. insulin resistance and type 2 diabetes • Breathing problems. flexible • Coping skills training for maladaptive coping responses o Social support o Problem solving skills o Cognitive restructuring • Psychotherapy for psychiatric disorders How Psychology Can Help: Advocate • Talk with day care/school/camp officials to advocate for special needs o Provide general information o Describe child’s regimen and its potential impact on the setting o Identify barriers to adherence and problem-solve ways to overcome them o Address problems that may arise 05/16/16 Lecture Childhood Obesity What is obesity? • Body Mass Index (BMI) o Weight (kg) divided by the square of height (m) o Interpreted differently for children .e. and asthma • Joint problems and musculoskeletal discomfort • Fatty liver disease. which are risk factors for cardiovascular disease (CVD) • Increased risk of impaired glucose tolerance.cdc.

stroke. and consistency • Family routines (eating meals and exercising together) • Divorce/separation and other stressors • Parenting behaviors. such as using food for a bribe or reward • Only children are more likely to be obese o Eating out of boredom or loneliness o Given big portions like adults o Sharing too much screen time instead of physical activity • Parents who push kids too much to excel in sports might cause burnout and an aversion for physical activity . arthritis. eat more in groups Larger bites Preference for high-fat and sweet foods. diabetes. obesity in adulthood is likely to be more severe • Obese children are more likely to become obese adults. or hoard it in their rooms The Family • Parents may mistake baby’s cues as signal that he wants food • Obese parents may be more rigid about food habits and food allocation. and criticize the child’s weight • The families of obese children tend to be less cohesive • Overprotective mothers and weak. high-calorie drinks Food is a source of comfort May lie about food. and some cancers Contributors to Obesity • Genetics/biology and medical conditions • Poor nutrition and eating habits • Lack of physical exercise • Psychosocial factors • Clinicians must address psychosocial factors when working with families and set appropriate treatment goals More about • • • • • • eating habits of obese children Snacking and binging.Long-term Health Consequences of Obesity • If children are overweight. • Adult obesity is associated with a number of serious health conditions including heart disease. more eating after 6pm Eat out more often. supervision. timid fathers is a common pattern • Absence of a parent may lead to overprotection and pampering • Role-models • What food is purchased • Time and money management • Setting limits.

The Family • • • • • • and Community Limited income and low education linked to obesity Healthy foods are more expensive Problems finding healthy food. lack of energy  less physical activity • The immune system o Stress  lowered immunity  illness  less physical activity o Stress activated HPA axis (excessive cortisol)  induce intraabdominal adiposity. Food deserts TV ads targeting children show unhealthy food Barriers to physical activity Fewer physical education classes. discrimination o Difficulty making friends. low energy. bullying. low motivation to exercise o Depression is associated with craving carbohydrates for some people • Anxiety o Due to parenting practices o Separation anxiety and stressful situations o Related to weight and food habits . ostracized • More likely to be bullies themselves • More likely to stay indoors (less exercise) and engage in emotional eating • Behavioral problems and issues in school • Self-reported low quality of life and self-esteem Stress and Obesity • Stress can trigger emotional eating as a coping mechanism (boredom. insulin resistance. too!) • Chronic stress may lead to inadequate sleep. and metabolic syndrome Mental Health • Depression  Obesity • Obese adolescents at risk for major anxiety and depressive disorders later in life • Chronic obesity and difficulty controlling weight predisposes children to depression • Depression during childhood associated with higher BMI in adolescence and adulthood o Poor sleep. humiliation. despite PE improving academic performance and reducing stress Peers • “Weight Bias”: The tendency to make unfair judgments based on a person’s weight o Teasing.

same therapies may be helpful • Working with parents • Eating three or more meals per week with the family: o Reduces odds of being overweight. such as binge eating disorder and bulimia nervosa o May start when family ridicules their appearance • Higher risk for poor emotional well-being. and compared to under developed nations . calories out (but it’s not that simple) • Strategies for more physical activity • Motivational Interviewing • Identify sources of stress and recommend resources and support • Because of similarity to addictions. further lowering self-confidence. and reducing motivation to change Assessment • “Sizing Me Up” self-report (5-13 yrs) o Emotional functioning o Physical functioning o School avoidance o Positive social attributes o Teasing/marginalization • “The Impact of Weight on Quality of Life – Kids Version” selfreport (11-19 yrs) o Physical comfort o Body esteem o Social life o Family relations Interventions • Calories in. disordered eating o Increases odds for eating healthy food Terminal Illness and Survivorship Death in Childhood • Considerably lower rates in the US compared to the past. and social difficulties • Low self-esteem can lead to persistent unhealthy behaviors. deepening frustration. poor social skills.• Dissatisfaction with body image in obese children (especially girls) o Associated with higher risk of eating disorders.

feelings. and needs • Drawings. coping. such as “going on a long trip” or “falling asleep” may be confusing to younger children • Listen to the child’s concerns. and communication styles for child and family o Family/caregiver support • Hospice: End of life (~6 months) • Should children be involved in end-of-life decisions? To what extent? Talking with Children about Death • Use language appropriate to developmental level • Euphemistic expressions. not just the illness o Concerns. finger paints. fears. together with the understanding that the medication and treatment will not be able to cure them Understanding of Death (Rushforth. 1999) • Recognition of illness as “serious” • Understanding the importance of treatments • Recognition of the illness an irreversible. and chromosomal abnormalities Stages Children Go Through When Facing Death (Rushforth. 1999) • Involves the following concepts: o Irreversibility o Finality and non-functionality o Universality o Causality • Becomes more sophisticated with age • Accelerated by education • Influenced by experience • The “greatest disservice” is trying to protect (hide) children from issues related to death and their own survival Different Types of Care • Palliative: Serious chronic illness. pain and symptom management. focus on the entire person.• Leading causes of death in US for children ages 5-14 are accidents and congenital malformations. deformations. metaphors. or books may be helpful Survivorship • In remission – cancer has responded to treatment and there are no signs or symptoms • Cured – doctors tend to refrain from saying “cured” because .

family.. thus delaying treatment of late-effects o Late-effects are under-estimated by survivor. such as task efficiency. and medical professionals Effects on Cognitive Functioning • Neurocognitive deficits. thus mimicking high-stress effects on the brain. 2010) o PTSD related to the number of physical late effects. approx. damage to the prefrontal cortex and anterior cingulate cortex may result in executive functioning deficits. may damage the developing brain • For example. 2012) o Four times risk of PTSD (Stuber et al. 14% of cancer survivors meet criteria for PTSD (Taylor et al. self-efficacy scores • Irritability and personality changes • Depression. which are linked to coping with stress • Childhood cancer survivors may experience difficulty eliciting secondary control coping responses. thus leading to greater emotional and behavioral difficulties • Chemotherapy includes large doses of synthetic glucocorticoid. Influences: . and somatization related to scarring and physical disfigurement and persistent hair loss • Some siblings may have increased risk of depression and distress o More depression in younger siblings and male siblings Psychosocial and Neurocognitive Functioning • Treatment..there are possibilities of the cancer coming back • Increased number of survivors due to improvements in medical care Medical Effects of Survivorship • Those who survive cancer may experience long-term medical problems • Survivors and their family may avoid talking about the illness and treatment received due to the trauma associated with the process. memory. anxiety. and emotion regulation are 50% higher in cancer survivors o Factors associated with increased deficits o Girls perform more poorly on shifting attention and sustained attention. being female. such as intense chemotherapy. boys perform more poorly on inhibition and working memory Effects on Psychological and Emotional Functioning • Post-Traumatic Stress Disorder and symptoms o After 2 years.

o Choice of coping strategy o Ability of the brain to process the strategy Effects on Social Functioning • Social isolation.. and emotional impairments o Higher insurance rates o Difficulty obtaining healthcare due to unemployment Impact of Cancer Diagnosis on Self and Relationships (Quinn et al. and bullying • An awareness of limitations and feeling of being perceived as “deficient” or “less” • An ability to express personal and social concerns and fears in an articulate and insightful way.. especially for those with neurocognitive. 2012) • Perceived sense of self • Behavior and regulation of emotions • Relationship with parents • Social relationships • Romantic relationships • Parenthood Parenting Styles and Adolescent Survivors (Eiser et al. loneliness. happy when there are positive outcomes) and painful when there’s the lack of gains  Try to make things seem fun  Focuses on things the child CAN do as opposed to prevention-focused . and to support other survivors • Adult survivors of childhood cancer: o Less likely to be married and have children. 2004) • Regulatory Focus Theory o Prevention-focused parenting  Concerned with pleasurable absence of negative outcomes (happy when there’s no negative outcomes) and painful presence when there are negative outcomes   Prevent things from happening  Look at the bad side of things  Ex: having hand wipes because expecting something bad o Promotion-focused parenting  Find it pleasurable to achieve positive outcomes (gains) (i.e. physical. but not more likely to be divorced o Less likely to attend college o Less likely to be employed full-time.

no formal research looking at pain management in children • Swafford and Allen (1968): “pediatric patients seldom need medication for pain relief” • 1974 – 52% of children received no pain medication after surgery such as nephrectomies. and smoking fewer cigarettes if one does smoke • Neurocognitive and emotional problems lead to poorer health behaviors o Physical activity o Dental care o Health screening procedures Positive Outcomes • Resiliency after surviving childhood cancer and other chronic/serious illnesses o “Benefit-finding” (Michel et al. 2010) Psychosocial Interventions for Survivors of Childhood Cancer • Early intervention should focus on health promotion o Encourage attendance at follow-up appointments o Increase awareness of late physical and psychological effects o Increase health behaviors • Neurocognitive functioning can be improved with intervention 05/23/16 The Experience of Pain in Childhood Do children feel pain? • Before 1970 . palate repairs and traumatic amputations ... significance of stressful life transitions (Sumpter et al..Behavioral Outcomes of Survivorship • Childhood survivors of cancer show more behavior and emotional problems o Age-appropriate performance on IQ • Survivors of meningitis showed greater behavior difficulties. 2012) • Poor “sleep hygiene”  fatigue and neurocognitive functioning • Lower rates of smoking. 2011) Survivorship and Health Behaviors • Increased risk of obesity (Green et al. 2009) o Post-traumatic growth (Devine et al..

usually well localized – can pinpoint where the pain is • Visceral: abdominal organs. throbbing pain (slow) . stomach aches. but is not persistent • Neuropathic pain: persistent pain in the central or peripheral nervous system in the absence of on-going tissue injury *burning or shooting pain • Psychogenic pain: persistent pain as a manifestation of psychological factors • Somatic sharp/stinging.dermal or epidermal layers. superficial . etc Pathophysiology of Pain • Nociceptors – what recognizes that your tissue is damaged/potential for damage  transmits messages that let your body know you’re in pain/some part of you is damaged o Free nerve endings at site of tissue damage o Purpose of nociceptors are to transmit pain impulses along specialized nerve fibers • Substantial gelatinosa. non-pain impulses can compete with pain impulses for transmission  A delta fibers: associated with sharp pain (fast)  C fibers: associated with dull. dull pain – can be characterized with nausea. aka “gate-keeper” o Regulates transmission of pain and other nerve impulses to the CNS o Located in the dorsal horn of spinal cord • Gate Control Theory o Since pain and non-pain impulses are sent along the same pathways. deepbones or deeper structures – damage to the outer layers of the skin or deep in the bones. peritoneum and pleura – difficult to localize. bloating.What is pain? • Nociception: the neural mechanism by which an individual detects the presence of a potentially tissue-harming stimulus • Pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage Types of Pain • Acute pain: pain associated with a brief episode of tissue injury or inflammation **difference between acute and chronic = 12 weeks of pain** • Chronic pain: consistent pain for 3+ months • Recurrent pain: pain that is intermittent across time and can be intense.

culture.e. previous experience. and relaxation may close the gate • Endorphins reduce the effectiveness of substance P. when you hurt yourself and grab that body part – it actually helps and works because you prevent the “pain messages” from being sent to your brain) Reaction to Pain • The thalamus and cortex of the brain detect A fibers and are associated with planning and action 1 *this is important so that you’re able to move and get away from whatever’s causing the pain • The limbic system. as well as the individual's psychological state. guarding Anorexia Lethargy Sleep disturbance Aggression Linking Pain and Stress • The experience of pain is stressful and activates the stress response pathways and disrupts the immune system Variations in the Experience of Pain • The pain stimulus is interpreted based on the context or meaning of the pain to the individual. A beta fibers: respond to touch and gentle pressure (i. and a host of other psychosocial variables. posturing. which enables pain to be transmitted across nerves in the brain and spinal cord *substance P is what transports the pain messages Reaction to • • • • • • Behavioral • • • • • • • • Pain Autonomic Nervous System is activated Neurological Respiratory Changes Metabolic effects Immune System Gastrointestinal Indicators of Pain Restlessness and agitated or hyper-alert state Short attention span Irritability Facial grimacing. hypothalamus. . and autonomic nervous system enable an emotional response to the pain o Anxiety may add to the degree to which the gates are open.

HR. O2 sat. often used for procedural and post-op pain  FLACC Pain Scale  Oucher Pain Scale  Faces Pain Scale Children’s Coping with Pain The social context and culture Previous experience with pain Cognitions. BP. behavioral state. evaluations. expression and sleeplessness o Neonatal Infant Pain Scale (NIPS)  Evaluates facial expression. and understanding Strategies o Hiding away o Fighting it o Making it better • Lu et al. (2007) o Lower pain intensity with positive self-statements and greater pain tolerance with behavioral distraction o Lower pain tolerance was found for those who seek emotional support and higher pain intensity for those who . eye squeeze.can be different to patients perspective **parents can better recognize their children’s pain levels/know the children better as opposed to doctors and nurses who are unfamiliar with the child Pain Assessment Tools • Newborn/ Infant: o CRIES  Developed for use in preterm and full term infants in ICU  Measures crying. the same noxious stimulus may cause different amounts of pain in different individuals based on personal characteristics Challenges with Assessing Children • Lower levels of verbal fluency / non-verbal children • May not verbally communicate presence of pain unless specifically asked • Pain highly individualized • Parents often called upon to provide pain ratings . legs and state of arousal o Premature Infant Pain Profile (PIPP)  Gestational age. O2 sat. and nasolabial furrow.• As a result. cry. brow bulge. breathing. HR. arms.

need to be careful what we give to teenagers.not necessarily true – just need to find a good balance for them • Giving narcotics to children is addictive and dangerous . that’s a different case . (2006) o Strategies of external distraction were more effective for younger children (7-9 years) and internal distraction was equally as effective for older children (10-14 years) Myths and • • • Misconceptions around Pain Active children cannot be in pain If children are asleep then they are pain free Generally there is a “usual” amount of pain associated with any given procedure • Infants don’t feel pain o Changes in subsequent responses to pain Pharmacologic Pain Control • Pain Medications include: o Opioids o Nonsteroidal anti-inflammatory drugs (NSAIDs) o Non-narcotic analgesics (acetaminophen) Myths and Misconceptions around Pain Medications • The less analgesia administered to children the better it is for them . but young children who have been through surgery or something.need to wean them off of medications slowly Non-pharmacologic Methods of Pain Control • Sucrose solution • Electroanalgesia • Biofeedback • Acupuncture • Distraction • Imagery • Relaxation and breathing techniques • Comfort measures Parental Illness and Death The Child as Caregiver • May be as young as 8 years .internalize/catastrophize • Piira et al.yes and no.

and support • Pretense and avoidance can be frightening to anyone in a stressful and painful setting. (Fiorini & Mullen. 10) When a Pet Dies • For many children loss of a pet is their first experience with death • Reactions to death of a pet across ages When a Sibling Dies • Associated with higher levels of behavior problems and lower social competence throughout the bereavement period • If children are informed about the dying sibling. never-ending process that results from a permanent or temporary disruprtion in a routine. change.Grief and Loss • Grief is an inevitable. especially a child • If children are involved in grieving of the family.• Single • Tasks o o o o o o The impact • • • • • • • • • parent families account for half of child caregiver arrangements Domestic General care or nursing Emotional support Intimate care Child care Others of Caregiving Emotions and psychological health Social relationships and activities Educational difficulties Family relationships Daily hassles Behavioral difficulties Physical health Parentifcation Positive outcomes Definition. Although loss is a universal experience. feelings. a separation. the causes and manifestations of it are unique to each individual and may change over time. This disruption. they show lower anxiety and greater tolerance/acceptance of less parental attention • Bereaved children need explanations. 2006. comfort. or separation causes pain and discomfort and impacts the person’s thoughts. p. or a change in a relationship that may be beyond the person’s control. it helps them to . and behaviors.

headaches. weakness • Increased illnesses and infections • Rapid heart beat • Acne • New habits or regression in behavior • Increased psychosomatic complaints Common Academic Responses • Inability to focus • Decline in grades • Incomplete work.learn coping strategies they can rely on in dealing with future losses Statistics • 1 in 5 children will experience the death of someone close by the age of 18 • 1 in 20 children will experience the death of a parent by the age of 18 Common Physical Responses • Stomachaches. trying to be perfect • Inattentiveness • Daydreaming • Increase in behavior problems at school • Lack of interest Common Social Responses • Withdrawal from friends • Withdrawal from activities and sports • Use of drugs or alcohol • Changes in relationships with peers • Change in family roles • Stealing. heartaches • Frequent accidents or injuries • Sleep disturbances • Loss of appetite or increased eating • Low energy. or poor quality • Increase in absences • Over achievement. shoplifting • Difficulty being in social situations that were once comfortable • Wanting to be physically close to safe adults Common Spiritual Responses • Anger at God • Questions of “Why me?” or “Why now?” • Questions of the meaning of life .

agitated at night o May ask questions over and over o Separation anxiety – can’t sleep alone. over clinging o Importance of talking to the child and giving her/him loving attention • 5-9 years o Beginnings of understanding of the finality of death. thoughts about life in the cemetery o Believes death is reversible o Clinging to favorite toys o Can become withdrawn. disinterest in play and food o Clinging to caregivers and refusal to let them out of sight o Irritability and crying o Changes in sleeping and eating patterns o Bowel/bladder disturbances o Consistency in routines and affection o Constant loving care is the key • 3 to 5 years o Asks questions concerning absence of the parent o Anger reaction to unfulfilled wish of parent’s return o Magical thinking. will ask for the missing parent o May become angry because parent doesn’t come back.• • • • Confusion about what happens after death Doubting or questioning previous beliefs Sense of despair about the future Change in values. depressed o Nightmares. but might not think of own death . questioning of what is important Factors Affecting Children’s Responses to Death • How the parent died • Religion and culture • Support available • Unfinished business • Characteristics of the child Child’s reactions to loss of a parent • 0-6 months: o Displays distress from loss by changing sleeping and eating habits o Reacts to grief reactions of others o Needs continuous loving care o Consistency in routines and affection • 6 months to 2 years o Doesn’t understand the permanence of the loss.

anxiety. fatigue. school performance. drug or alcohol use o Difficulties controlling mood o May search for or re-evaluate their own philosophy of life and death How to react • Is death like sleeping? • Why did they die? • Will you die? Will I die? • Did I do or think something bad to cause the death? • Will they come back? • Is she cold? What will he eat? • Why did God let this happen? Child Suicide • Child suicide is influenced by immature understanding of death: o Death understood as a transient and reversible state o Death as a vehicle to a happy reunion with the deceased or as a gateway to a happier situation Reactions and Grief Strategies • Regression to an earlier developmental stage • Hyperactivity • Emotional outbursts . anger. distress. isolated o Increased risk taking. depression o Difficulties concentrating o Decline in school work o May complain of physical pains. denial. anger reactions o Lacks verbal ability to express strong feelings of grief o May act as though nothing happened (defense mechanism) o Death is represented by monsters and ghosts o Important to have trusting relationship which allows the child to talk about their grief and distress • 9-12 years o Understands death is final o Difficulties concentrating o Curiosity about what happens when someone dies o Identifies with deceased – imitates mannerisms o Has the vocabulary to express grief but may choose not to o Begins to search for their own philosophy of life and death • Adolescents o Shock. drowsiness o Become withdrawn.o May feel responsible for the death o Grieving manifest in changes in behavior.

writing. music. and dance • Faith/spirtuality based • Cultural practices • What mistakes do some parents make when talking to children about grief? • Long-term Consequences of Parental Death During Childhood • Lower blood pressure and underlying physiology indicating a toughening. or “stress inoculation” .• Overprotectiveness of the surviving parent • Constructing the deceased parent William Worden’s 4 Tasks of Mourning • To accept the reality of the death • To experience the pain of the death • To adjust to an environment in which the deceased is missing • To find an enduring connection with the deceased while embarking on a new life Interventions with Children who are Grieving • Individual and family therapy • Group counseling or support groups • Bibliotherapy • Use of art.