Daily Archives: September 21, 2010

Sleep Disorders in Childhood


There are a number of theories regarding the purpose of sleep.  “Sleep may provide a period of restoration in which deficits in somatic and central nervous system tissues are repaired.”  (Netherton, Holmes, & Walker, 1999, p. 415)  What I question is… wouldn’t we be able to detect that process (cellular creation/division)?

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It has been suggested that sleep facilitates information processing and memory consolidation.  This, too, seems plausible given the effects of sleep deprivation.  “Fatigue, excessive sleepiness, decreased attention, decline in perceptual, cognitive, and psychomotor capabilities and performance, regressive behavior, and disoriented though may result from prolonged sleep deprivation.  (Netherton et al., 1999, p. 415)

The “cycle of sleep” is a concept I found helpful to be able to conceptualize the process that takes place during sleep.

“While psychopathology is often comorbid with sleep disorders in adults, it is rarely so in children.”  (Netherton et al., 1999, p. 420)  NHW throws this out as a fact, but they don’t really give a reason why that is the case?

With regard to assessment, I very much approve of the use of sleep diaries as an effective way to document the course of events in a sleep-wake cycle.  We currently employ this tool with a couple clients of mine with a great deal of success.  One individual, in particular, had to take “the long way around” (which was particularly hard for the night staff I might add) but eventually we got them on a schedule that was amiable for all.

“Treatment of sleep disorders is designed to address both the symptoms and the causal factors of the disturbance; therefore, it is essential to cast a broad net in assessment to identify the likely etiology of a sleep disruption.”  (Netherton et al., 1999, p. 420)  I’m not sure it can be said better than that, great piece of writing in my opinion.

With insomnia, you sleep too little… with hypersomnia, you sleep too much.  Just FYI.

With regard to treatment, it would appear that the first and most important step is to regulate sleep hygiene.  This means we set and enforce a bedtime routine, and we foster the development of an environment that is conducive to sleep.  Eating and drinking (especially liquids that contain caffeine) should be limited close to bedtime.  (Netherton et al., 1999, p. 428)  We should assess all medications and determine if any possess stimulant qualities.  A “bedtime ritual” should be established and adhered to, including grooming and personal hygiene, flossing and brushing teeth, and using the bathroom.  Although this may be the case for some people, I personally disagree with the concept that bathing is a stimulant.  Personally, I have difficulty sleeping if I don’t bathe at night… it’s relaxing.  Matter of fact, sitting in the hot tub on a cold winter night is the sure fire way to make sure I get a great night of sleep.

I was also particularly interested in the relaxation training suggestion.  One method in particular that I was taught as a child, and that I endorse, is conceptualizing first that your lower extremities (starting with your feet) are “falling asleep.”  I progressively work my way “up” until I reach my head.  Usually, but the time I get to my arms, I am out like a light.  Mileage may vary, but it is one relaxation technique that worked for me as a kid.

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Eating Disorders = BIG BUSINESS


“Weight discrimination and the resulting obsession with thinness are rampant and recalcitrant.  I believe that, in order to make any kind of a dent in this field, we all need to combat these pernicious influences.”  (Netherton, Holmes, & Walker, 1999, p. 412)  Amen.  The weight of the media, the “diet food industry,” and the purveyors of a “healthy lifestyle” propagate this issue… without a doubt.  Losing weight is BIG BUISINESS, and there are huge profits to be made for those that offer obese people the glimmer of a stereotypically thin body.

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I also appreciated the acknowledgement on the pressure exerted by managed care.  Eating disorders appear to be particularly “deep seated” and ill suited for half a dozen one hour sessions.  Correcting inaccurate perceptions, relabeling cognitions of visceral and affective states, and redrawing boundaries… this kind of work takes time… more time than managed care often provides.  This is yet another example of the effect managed care will continue to have for as long as it is the primary method of seeking out psychological assistance.

I was suitably surprised at the long-term mortality rate… suggested to be over 10%.  (Netherton et al., 1999, p. 399)  With a roughly 1 in 10 shot of succumbing to starvation, suicide, or electrolyte imbalance; you would think this particular set of disorders would get more research attention.  The fact that there is still limited epidemiological data is frustrating… perhaps the difficulty obtaining the data is related to the relative secrecy and shame associated with the disorders themselves?

Like the BM text, NHW jumps on the multi-determined etiology bandwagon.  It’s hard to disagree with since biological, familial, sociocultural, and personality factors all seem to be plausible.  The differences in family characteristics were particularly interesting.  “Bulimic families tend to be characterized as disengaged, chaotic, and highly conflictual and as having a high degree of life stress.”  Conversely, “anorexic families tend to be characterized as enmeshed, overprotective, and conflict avoidant.”  (Netherton et al., 1999, p. 400)  That’s a strange clinical picture that seems to suggest that there might be a single underlying biological cause for EDs in general, but that familial and personality factors may play a role in its manifestation.

The list of comorbid disorders we need to consider during the assessment process is long and fairly inclusive.  “Depression, anxiety disorders, dissociative disorders, substance abuse, and personality disorders” are on the forefront of the disorders we should be checking for.  (Netherton et al., 1999, p. 401)  Furthermore, NHW suggest we assess treatment history, as well as suicide attempts and self mutilative behaviors (cutters).

Pharmacological interventions employing antidepressants have been particularly successful.  This text only cites 3 studies that have employed SSRI class antidepressants, but they report “significant improvement with 60-80 mg dosages (of Prozac) compared to placebo.”  (Netherton et al., 1999, p. 407)  I think I am going to dig deep into some more recent research to see of this trend holds up, there has to be more than three studies on it by now.

I like the idea of a behavioral contract… not just for eating disorders, but for any disorders which involve “behavior.”  I am inclined to agree with the statement “the contract provides structure and predictability.  Expectations, rewards, and consequences are delineated so that all people involved (patient, treaters, families) know what is expected at all stages of treatment.”  (Netherton et al., 1999, p. 407)  My question is this… realistically, what “consequences” are there if we are dealing with outpatient treatment?

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Gender Identification Disorder (GID)


The term gender identity, as used in the diagnosis of Gender Identification Disorder (GID), generally refers to issues surrounding the basic knowledge of understanding that he is a male or that she is a female.  These individuals have a persistent cross-gender identification that frequently manifests in a stated desire to be (or insistence that he or she is) the other sex.  Furthermore, individuals present with persistent discomfort with gender roles (Criterion B), although this particular criterion is quite ambiguous as it would seem that anyone who self-refers themselves to a therapist for diagnosis or treatment of GID is under some form of duress?

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“Children who met the complete criteria for GID were significantly younger, of a higher social-class background, and more likely to come from an intact, two-parent family than the children who did not meet the complete criteria.”  (Netherton, Holmes, & Walker, 1999, p. 370)  Despite this apparent correlation, very little is known about the etiology of GID or the antecedents that would or could contribute to its onset or maintenance.   What is known, is that the wish to change sex is negatively related to age, thereby making older children less likely to verbalize wishes to proceed with sex change procedures (hormonal treatment, surgical procedures, etc).  It has been suggested that this may be because of social desirability factors, but I suspect it is also due to the permanency of the procedures themselves.  What if they proceed and they change their minds?  What a quandry?

I was puzzled by the statement “unlike adult females with GID, who are invariably attracted sexually to biological females, adult males with GID are about equally likely to be attracted to biological males or females.”  (Netherton et al., 1999, p. 372)  What could possibly account for such a difference?  This leads me to believe that the male and female versions of this disorder are qualitatively different.

I am unsurprised that boys are referred more often than girls for concerns regarding GID.  I think this is likely driven by fathers who innately have different expectations for their sons than they do their daughters.  “Adults are less tolerant of cross-gender behavior in boys than girls…”  (Netherton et al., 1999, p. 375)  As a result, it has been suggested that girls would be required to display more extreme cross-gender behavior than boys before parents sought out a clinical assessment.  When someone refers to a girl as a “tom-boy” I think… “cute.”  When someone refers to a boy as a “sissy,” there is a distinctly negative connotation.  There is no culturally neutral term for a boy who sexually identifies with the female gender… so, despite the fact that girls are more likely to display masculine behavior compared to boys who display feminine behavior… the latter not the former are referred more often.  Seems backwards to me, but hey, that’s culture.

I was suitably surprised that the typical age of onset is so early!  Pre-school years (or even earlier) is when GID traits typically begin to appear… with nearly 90% of kids who intend to cross-dress “coming out” by their 5th birthday.  Differences have appeared as early as a child’s 2nd birthday… which may suggest some genetic/biological or prenatal influence on the phenomenon. (Something other than environmental, in any event)

Transvestic Fetishism (TF) typically manifests during adolescence or adulthood, unlike GID which typically manifests in early childhood.  It is perceived to occur almost exclusively in biological males, although a few cases of adult females demonstrating cross-dressing sexual arousal have been reported.  (Netherton et al., 1999, p. 384)  Unlike GID, childhood gender development of adolescents with GF is typically heterosexual (masculine).  TF would appear to serve some typify of self serving function, and as a result, the nature of cross-dressing in TF and in GID is qualitatively different. (Netherton et al., 1999, p. 386)  Some have suggested that TF develops as a reaction to “petticoat punishment” (forced cross-dressing during childhood) although this is a very rare occurrence.  (Netherton et al., 1999, p. 388)

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.