03/28/16 Lecture 1

04/04/16 Lecture 2
Defining Health, Illness, and Well-Being
Health
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?
Childrens 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 dont really
know; as older, can see the difference between health and
illness
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 persons biological, psychological, or social
systems
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

appraisal)
o Ex: boss giving you a project
Then, we decide if the event or situation is stressful, and in what
way
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
individuals ability to cope and resources available to do so

Coping Styles
Problem-focused
o Fixing/attacking the problem
o Cant always be done (ex: bringing back someone whos
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 someones passed
away
o Doesnt work if the situation is like paying the bills
Meaning-focused
o Drawing on ones own beliefs and values
o Getting some meaning or purpose from it
o Ex: taking care of a loved one whos passing away can be
difficult to deal with the loss can focus on taking care of
the person, but cant prevent them from passing away
o Attaching meaning to something giving meaning to
something
Ex: in someones final days, youre able to give
meaning and love to something
Stressors
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
houses,
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
divorce,
Modern new stressors that were not equipped to deal with
o Parent losing job, divorce, moving homes idea of
separation
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,
1980)
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 havent
slept/when youre stressed
Childrens 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
Childrens understanding differs by illness type (Myrant & Williams,
2005)
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
Cortisol
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
months
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

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, leading to a major mindbody influence

Over- and under-production of cortisol in childhood

Over-production (stress response or infection) can lead to growth
retardation
o Cushings disease
Under-production can lead to immune over-activity and
autoimmune disorders
o Addisons 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, and over-activity of Th2 is related to
asthma. These conditions are not likely to co-occur.
(if one is high, 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, 1976): Emphasized adaptability of the stress
response; Stages:
o Alarm
o Resistance body copes physiologically by producing
hormones
o Exhaustion: the body runs out of stress hormones,
negatively impacting health

Robert Sapolsky (1994): Vulnerability to illness is not caused by

stress hormones running out, 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, overcrowding, extremes of temperature,
physiological alterations necessitated by infection
Allostatic load: repeated lifetime stress (threat, helplessness,
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 - having a high activity over a longer period
of time and no recovery
Inadequate response - 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, but is
not always feasible

Measurement of Psychosocial Factors

Stress
Coping responses
Social support
Temperament
Family socioeconomic status
Etc.
For younger children, 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
Childrens Hassles Scale (Kanner, 1987)
(Screenshot)
Childrens Coping Questionnaire
http://summit.sfu.ca/system/files/iritems1/6875/b1774989x.pdf
The Coping with Cyberbullying Questionnaire
http://www.mdpi.com/2075-4698/5/2/515/pdf
Social Support Questionnaire for Children
http://etd.lsu.edu/docs/available/etd-07052011175139/unrestricted/gordondiss.pdf
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 injection, look for a
reaction after a few days
o Deliberate exposure (viral challenge)
Neurotransmitter and Endocrine Markers of Stress
Originally via blood and urine, but saliva testing is more common
now, especially for cortisol
o Cotton swab in mouth for 1-3 minutes; may be flavored for
children
o Timing is important

 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, 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, implemented as a
randomized controlled trial (RCT)
Health Outcomes: Acute Illness
Upper respiratory infection
o Follow healthy children for 6 months, track cold and flu onset,
duration, and intensity
Other minor symptoms: headache, stomach ache, 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; 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, BBC TV show documenting the lives of 25
children born in 2000 for 20 years

 https://www.youtube.com/watch?v=d9eno8wUrUs
Is this ethical??
Ethical Issues
The history of pediatric experimentation is largely one of child abuse Lederer & Grodin, 1994
Informed Consent
Informed consent is the process of obtaining permission
before administering tests or interventions. Requires
informing research participants of:
o Procedures (tests, surveys, videos)
o Alternative treatments
o How the data will be used
o Potential risks, including breach of confidentiality
o Potential benefits
o Individual rights, 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 cant give consent because theyre too young to understand
ex: a kid made fun of a kid for stuttering made fun of kids who didnt 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 Name, address, scores, video, etc.
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, such as asking about
drug use or sexual behavior, but does not allow the researcher to
refer for help or follow up
Coercion
No pressure to participate is permitted
o E.g., no threat of punishment
o Parents are often given a gift card or small cash amount for their
childrens participation. Is this ethical?
Money should only be compensating for time or inconvenience
Deception and Debriefing

 Deception: withholding information

o Must be carefully considered, avoided if harmful, kept to a
minimum, 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, 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; placenta develops; 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 mothers bloodstream
to the embryo/fetus
o Transports carbon dioxide and metabolic waste away from the
embryo/fetus to the mothers 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

 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,
ACTH, cortisol) and endorphins throughout pregnancy culminate
in labor and delivery
The Stress Response During Pregnancy
Basal levels are high, 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.g., motor movement) -- agitation
Cardiovascular responses (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.e. babies having a preference for
carrots because mothers eat carrots during prenatal
period)
Voices, rhymes, 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

 Preterm birth rate in US (2013) at 15 year low of 11.5%

o Can be related to effects of medical care
Effects of Prenatal Stress on Birth Outcome
Swedish study using population registries (Class et al., 2011)
o 2.6 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),
life-event stress has the greatest impact on preterm birth or
reduced size
Danish study of 1.38 million mothers (Khashan et al., 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., 2009: 13,000 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.g., 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, but smaller head circumference (Mulherin Engel et al.,
2005)
The Role of CRH and Cortisol
Stress reactivity is dulled in the mother, 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, but if levels increase too
rapidly, too early, 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)

 Most studies confirm that the 2nd trimester is a crucial time for
stress exposure influencing birth outcomes
Ellman et al., 2008: maternal stress hormones in the blood and
newborn neuromuscular (e.g., muscle tone and flexibility) and
physical maturation (e.g., of skin, eyes, ears, genitalia)
o Higher cortisol levels at 15, 19, and 25 weeks (2nd trimester) and
CRH at 31 weeks (3rd trimester) were associated with poorer
maturational outcomes in males
Entringer et al. (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, but not gestational
length
Subjective mood may not be a good predictor of birth
outcome
Bolton et al. (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, 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, cognitive, and temperamental outcomes
o i.e. mental temperament, anger, poor recovery from stimuli, etc.
Bosquet Enlow et al. (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, some indication that mild stress is beneficial

o Rothenberger et al. (2011): mid-pregnancy stress and depressive

feelings associated with less infant crying and fussing at 3 and 5
months. Not related to cortisol.
Effects of Prenatal Stress on Adolescence (11 years) and Adulthood
Very few studies why??
Effects on cortisol
o OConnor et al. (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, yet flattened,
diurnal cortisol profile in children. For girls, this profile was
related to depressive symptoms
o Wust 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. David Barkers Hypothesis (1986): the poorest areas of
England were the same areas with the highest rates of heart
disease.
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, such as Type 2 diabetes
poor nutrition during prenatal period sets fetus up to think this will be the
circumstances it will have when its born but then when born, 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. Individuals in utero:
First trimester: normal size, but with high blood pressure,
diabetes, obesity
Second trimester: higher risk of cardiovascular disease
Third trimester: born small and stayed small their entire
lives; no obesity or disease
o These changes create a tag on DNA that can be passed down:
epigenetics

 DNA is not destiny: http://www.raisingofamerica.org/dna-not-destiny

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; genes that were silenced grew to be brown
and thinner
Epigenetics signals your cells and genes to be active or silent
o Ex: emotions, weight, size, color
Mice that were given BPA found in plastic offspring had
greater defects, more health issues, bigger and obese, higher
heart disease rate, etc.
Stressful environment led to low licking mother mom mice
couldnt tend to her offspring very well because of the lowresource environment she was in
Growing stressors = low finances, anxiety, job losses, working
and financial stability, etc can effect children as well
Topic 5)
The Experience of Stress During Childhood
Signs of Stress in Children
Trouble eating, relaxing, or sleeping (daily activities)
Increased clinginess, whining, crying, or fighting (emotional stems)
Recurring headaches, tummy aches, or neck pain (physical aches)
Increased irritability, sadness, panic, anger, or anxiety (mood changes)
Becoming withdrawn
Behavior problems, such as biting, acting out, impulsiveness, poor
listening
Nervous habits like nail biting, hair twisting, thumb sucking
Overreacting to problems
Unusually low energy or high energy and restlessness
Causes of Stress
Life changes
Problems with peers: being bullied, feeling different, 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?

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, but
then increased immunity at age 6-11 years
The Transition to School
Social stressor for typically developing children; involves social
evaluation and novel social and physical challenges
Cortisol levels may increase in the 6 months before school begins
in anticipation, rise with the start of school, and adaptively
decline 6 months later
Children with more extroverted or impulsive temperaments tend
to have higher cortisol levels, 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., 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
children who were physiologically more reactive showed higher
rates of illness if in a high-stress environment
**Just because it was reported doesnt mean it was actually true
o Low-reactivity children did not show higher rates of illness even
in a high-stress environment didnt matter what environment

you put them in; the stress didnt 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, neglect, malnourishment = toxic stressors
Even subtle forms of child maltreatment, 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, 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. (2001) found low cortisol in adult children of
Holocaust survivors, indicating an intergenerational transmission
of the low-cortisol response profile seen in PTSD
o Even though the kids didnt experience the holocaust, they still
had low cortisol
Cryssanthopoulou et al. (2005): for children with high family
stress, 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 al. (2010): Child abuse is associated with an increased risk
for coronary heart disease
Nicolson et al. (2010): In a sample of adults with fibromyalgia or
osteoarthritis, childhood trauma was related to an elevated
cortisol response, which may influence the onset and severity of
the condition
Kiecolt-Glaser et al. (2011): The experience of multiple

adversities during childhood was associated with reduction in

telomere length and was projected to reduce lifespan by 7-15
years.
Communicating Stress
Common finding: disparity between the experienced, perceived
stress and physiological level of stress (cortisol). Why??
Parents may not recognize stress in children. 69% say their
stress doesnt affect their child, 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 dont know how to communicate what theyre feeling
therefore theyre not a good measure of stress
o Also, parents dont recognize when their kids experience stress
Biological responses may be a more definitive way to measure
stress and its short- and long-term outcomes
New Modern Stressors?
Busy schedules and lack of free play?
Lost Adventures of Childhood: https://www.youtube.com/watch?
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 fear, stress from needing to be
watched every moment, stress from having a structured
schedule not playing outside because they have other
things to tend to like soccer practice or piano practice, etc)
04/18/16 Lecture 4
Childhood Asthma
What is Asthma?
Chronic disease involving inflammation of airways into the
lungs, called bronchial tubes
Certain triggers can cause swelling and tightening of bronchial tubes
and muscles around them
Coughing, wheezing, shortness of breath, and/or chest tightness
Severe attack: inability to speak, restlessness, confusion, sound of
grunting, exhaustion, blue skin
Prevalence and Etiology
Approx. 7 million children affected (See Chart)
Girls more affected than boys

 Genetic and environmental factors play a role

o Heritability estimate: .62
**if kids were more exposed to factors that triggered asthma at a
young age, 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, body sprays, etc)
Diagnosis and Assessment
Medical history
Tests of lung performance, such as spirometry
Allergy testing should know what youre 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.g., aspirin, ibuprofen, beta-blockers)
Viral and bacterial infections
Exposure to cold, 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.aaaai.org/Aaaai/media/MediaLibrary/PDF
%20Documents/Libraries/NEW-WEBSITE-LOGO-asthma-action-

plan_HI.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, Atrovent, Spiriva
1
Long-term control
Taken daily to control airway inflammation and treat symptoms
Several types: Inhaled corticosteroids (Flovent), leukotriene
modifiers (Singulair), mast cell stabilizers, theophylline, longacting beta-agonists (Symbicort, Advair), injectable antibody that
blocks allergic inflammation (Xolair), allergy medications
For serious cases of asthma, 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, 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, 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, including having to live
differently to avoid triggers
Psychosocial Issues
Weil et al. (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

wheeze and poor functional status

Stauenmayer (1981)
o The amount of debilitation/body weakening experienced by
children was related to:
Parental anxiety
Fathers 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 childrens
manipulations)
Behavioral and Emotional Effects
Anxiety, which can exacerbate symptoms
Behavioral and Emotional Effects
Depression and loneliness; 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 lungs capacity, 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, self-worth, and self-esteem
Communication with family, friends, 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

asthma, 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, take notes regarding:
Challenges faced by children with asthma and their families
Asthma management esp. revolving around the families whats the
familys surroundings like, whats their schedule, etc.
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. 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

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.g., pain and disability)
**chicken pox, meningitis, cold and flu, measles, leukemia certain forms
since it can be treatable, strep throat (if left untreated, 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, neglect of other children, needing to be a
caregiver, constantly being worried and stressed,
Childrens Understanding of Acute Illness
Childrens causal attributions are important and may involve
acceptance and/or self-blame
How to speak with children about acute illness
-- need to assess childrens understanding of their illness, 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

o Parents with one child worried more about illness

**misuse of antibiotics can cause resistance
Parents Decisions Regarding Child Health
Examples: Screening, medication, 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 childrens medical care?
In 2009, 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.youtube.com/watch?v=Hx_9uNLyEmQ
Case Discussions
o Parents denied daughter of treatment due to religious beliefs
parents turned to prayer, not doctors
o Should there be restrictions of religious beliefs? Whats 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, then yes. But if not, 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,
cognition, behavior, physiology, and the environment in response
to stressful events or circumstances
Coping behaviors utilized are influenced by developmental level
(biological, psychological, social)
Coping Subtypes (Compas et al., 1997)
o Primary control coping: Action
o Secondary control coping: Adaptation

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,
but not all?
Parents who were shocked by a diagnosis communicated more
information, 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.
Optimism
o Communicate benefits of treatment only
2.
Realism
o Communicate side effects of treatment plus benefits of
treatment/hope
3.
Pessimism
o Communicate side effects of treatment only
4.
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, 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 Childrens Hospitalization
Before the advent of childrens hospitals in the 1850s, children
were rarely hospitalized
Paternal visitation was encouraged until the late 1800s, when
they were restricted due to risk of infection and parental
interference with care


o
o
o

Late 1800s through 1950s

Restricted parent visiting hours
Lack of a child-centered environment
James Robertsons films https://www.youtube.com/watch?
v=s14Q-_Bxc_U
It is now common for a parent to stay with their child in the
hospital, but what stressors remain?
1 **being in an unfamiliar/uncomfortable environment, lots of
overwhelming factors different nurses coming in and out, a lot
of chaos going on (monitoring, medical equipment, etc)
Childrens Fears and Concerns about Hospitalization (Coyne, 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, because parents can help with daily
care, play, and social/emotional well-being
Hospital stay lengths should be kept to a minimum; parents
should provide car at home, if possible.
Intensive Care Treatment (Colville, 2012)
Acute emergencies, such as car accidents, burns, infections
Although children are frequently sedated, 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, >1 year?)
Gradual onset and development
Worsens over time
Can involve multiple bodily systems
Can be mild to severe or terminal
Often managed, rather than cured

 May involve frequent doctors visits and may impact social life and
school attendance
**HIV/AIDS, obesity, 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. Examples:
Obesity
Myopia
Nature Deficit Disorder: Chronic illness with long-term
consequences?

Chronic Illness
Interrupts
o Parental attachment
o Learning, playing, and socialization
o Regular activities, such as sports, games, 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 Childrens) 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, physical, and nutritional needs, but also
foster independence
o Own emotional functioning and support of the child
o Planning, preparing, and utilizing resources
o Communicating with family, friends, doctors

Uncertain role (parent, caregiver, 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. May become a hidden patient
o
o
o

Childrens Accumulative Stressors

Medical sources
o Hospitalization, recurring symptoms, pain, frequent blood draws,
growth failure, threat of shortened life span
Psychosocial sources
o Separation from close family members, social isolation, feeling
like an outcast, rejection
Children with HIV
Moss et al. 1998: Children with HIV show a decrease in positive
social self-concept over time, 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) Ericksons Psychosocial Stages:
During different stages of childhood (the age theyre at), chronic
illness can disrupt favorable outcomes due to crisis and lead to
instead unfavorable outcomes
Ex: trust vs. mistrust, autonomy vs. doubt, initiative vs. guilt, identity
vs. confusion, tec.
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

 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 failure
o Guilt thinking the illness is a punishment

 Supportive interventions
o Encourage relationships with same-gender and oppositegender
peers
o Clarify that the cause of childs 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 childs condition,
abilities, 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, 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, assertiveness, 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

o Age groups
o Settings
Improved social, emotional, and cognitive development in
children
Mechanism: social support and bonding; 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, resulting in permanent insulin deficiency
Insulin regulates glucose metabolism, which is essential for growth,
activity, wound healing, and brain function
Blood Glucose Level
As a result of insulin deficiency, blood glucose levels often deviate from
normal range, 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, leads to ketoacidosis
o Acid in blood damages organs
o Can be fatal
Hypoglycemia: Symptoms

Long Term

Shaking
Fast Heartbeat
Sweating
Anxiety
Dizziness
Hunger
Impaired Vision
Weakness
Fatigue
Headache
Irritability
Not likely to be fatal, 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. 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.e. 16 year old vs. 3 year old

Diabetes Assessment
Self-report instruments
o Johnsons 24-hour Recall Interview
Conducted separately with child/parent
o Self-Care Inventory
Completion of 14 diabetes-related tasks
https://www.psy.miami.edu/media/college-of-arts-andsciences/psychology/documents/faculty/alagreca/SCI-R.pdf
o Problem of social desirability changing your information to
conform to societys 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 doesnt utilize the sugar instead its just being stored
causes weight gain) (insulin also changes the water retention of
your body)
To prevent weight gain, needs to keep better track of what
youre eating
Degree of perceived interference in daily life
o Management requires adherence to multiple daily tasks at home,
school, and in other social settings
Social pressure may negatively affect adherence
Skills needed for good diabetes management:
Ability to appreciate future consequences
Impulse control

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, warmth, encouragement, and empathy
o Reasonable goals appropriate for childs 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, yelling, name-calling, mind reading
o Improve non-verbal communication

Eye contact, fidgeting, smiling

How Psychologists Can Help: Coping with Stress

1
Support from health care professionals
o Encouraging, empathetic, 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 childs 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 - based on percentiles from
CDC national surveys (~1960s and 1970s)
o https://nccd.cdc.gov/dnpabmi/Calculator.aspx
Prevalence of obesity has increased over the past 40 years, but not for
all age groups, and has since leveled off (~17% of children and
adolescents; CDC)
o Calculator: https://nccd.cdc.gov/dnpabmi/Calculator.aspx
Immediate Health Consequences of Obesity
High blood pressure and high cholesterol, which are risk factors
for cardiovascular disease (CVD)
Increased risk of impaired glucose tolerance, insulin resistance
and type 2 diabetes
Breathing problems, such as sleep apnea, and asthma
Joint problems and musculoskeletal discomfort
Fatty liver disease, gallstones, and gastro-esophageal reflux (i.e.,
heartburn)

Long-term Health Consequences of Obesity

If children are overweight, obesity in adulthood is likely to be
more severe
Obese children are more likely to become obese adults.
Adult obesity is associated with a number of serious health
conditions including heart disease, stroke, diabetes, arthritis, 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; more eating after 6pm
Eat out more often; eat more in groups
Larger bites
Preference for high-fat and sweet foods; high-calorie drinks
Food is a source of comfort
May lie about food, or hoard it in their rooms

The Family
Parents may mistake babys cues as signal that he wants food
Obese parents may be more rigid about food habits and food
allocation, and criticize the childs weight
The families of obese children tend to be less cohesive
Overprotective mothers and weak, 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, supervision, 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

The Family

and Community
Limited income and low education linked to obesity
Healthy foods are more expensive
Problems finding healthy food; Food deserts
TV ads targeting children show unhealthy food
Barriers to physical activity
Fewer physical education classes, despite PE improving academic
performance and reducing stress

Peers
Weight Bias: The tendency to make unfair judgments based on
a persons weight
o Teasing, bullying, humiliation, discrimination
o Difficulty making friends, 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, too!)
Chronic stress may lead to inadequate sleep, 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, insulin resistance, 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, low energy, 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

 Dissatisfaction with body image in obese children (especially

girls)
o Associated with higher risk of eating disorders, such as binge
eating disorder and bulimia nervosa
o May start when family ridicules their appearance
Higher risk for poor emotional well-being, poor social skills, and
social difficulties
Low self-esteem can lead to persistent unhealthy behaviors,
further lowering self-confidence, deepening frustration, 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, calories out (but its not that simple)
Strategies for more physical activity
Motivational Interviewing
Identify sources of stress and recommend resources and support
Because of similarity to addictions, same therapies may be
helpful
Working with parents
Eating three or more meals per week with the family:
o Reduces odds of being overweight, 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 compared
to under developed nations

 Leading causes of death in US for children ages 5-14 are accidents and
congenital malformations, deformations, and chromosomal
abnormalities
Stages Children Go Through When Facing Death (Rushforth, 1999)
Recognition of illness as serious
Understanding the importance of treatments
Recognition of the illness an irreversible, together with the
understanding that the medication and treatment will not be able to
cure them
Understanding of 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, not just the illness
o Concerns, fears, coping, 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, such as going on a long trip or
falling asleep may be confusing to younger children
Listen to the childs concerns, feelings, and needs
Drawings, finger paints, 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

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, thus delaying treatment of late-effects
o Late-effects are under-estimated by survivor, family, and medical
professionals
Effects on Cognitive Functioning
Neurocognitive deficits, such as task efficiency, memory, 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, 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, approx. 14% of cancer survivors meet criteria for
PTSD (Taylor et al., 2012)
o Four times risk of PTSD (Stuber et al., 2010)
o PTSD related to the number of physical late effects, being
female, self-efficacy scores
Irritability and personality changes
Depression, anxiety, 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, such as intense chemotherapy, may damage the
developing brain
For example, damage to the prefrontal cortex and anterior
cingulate cortex may result in executive functioning deficits,
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,
thus mimicking high-stress effects on the brain. Influences:

o Choice of coping strategy

o Ability of the brain to process the strategy
Effects on Social Functioning
Social isolation, loneliness, 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, and to support other survivors
Adult survivors of childhood cancer:
o Less likely to be married and have children, but not more likely to
be divorced
o Less likely to attend college
o Less likely to be employed full-time, especially for those with
neurocognitive, physical, 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., 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., 2004)
Regulatory Focus Theory
o Prevention-focused parenting
Concerned with pleasurable absence of negative
outcomes (happy when theres 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. happy when there are positive outcomes) and
painful when theres the lack of gains
Try to make things seem fun
Focuses on things the child CAN do as opposed to
prevention-focused

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;
significance of stressful life transitions (Sumpter et al., 2011)
Survivorship and Health Behaviors
Increased risk of obesity (Green et al., 2012)
Poor sleep hygiene fatigue and neurocognitive functioning
Lower rates of smoking, 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., 2009)
o Post-traumatic growth (Devine 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 - 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, palate repairs and traumatic amputations

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, 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; superficial - dermal or epidermal layers; deepbones or deeper structures damage to the outer layers of the skin or
deep in the bones; usually well localized can pinpoint where the pain
is
Visceral: abdominal organs, peritoneum and pleura difficult to
localize; dull pain can be characterized with nausea, bloating,
stomach aches, etc
Pathophysiology of Pain
Nociceptors what recognizes that your tissue is damaged/potential
for damage
transmits messages that let your body know youre 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, 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, non-pain impulses can compete with pain impulses for
transmission
A delta fibers: associated with sharp pain (fast)
C fibers: associated with dull, throbbing pain (slow)

A beta fibers: respond to touch and gentle pressure (i.e.

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 youre able to move and get away
from whatevers causing the pain
The limbic system, 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, and
relaxation may close the gate
Endorphins reduce the effectiveness of substance P, 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, posturing, 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, as well as the individual's
psychological state, culture, previous experience, and a host of
other psychosocial variables.

 As a result, 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 - can be
different to patients perspective
**parents can better recognize their childrens 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, O2 sat, HR, BP, expression and
sleeplessness
o Neonatal Infant Pain Scale (NIPS)
Evaluates facial expression, cry, breathing, arms, legs and
state of arousal
o Premature Infant Pain Profile (PIPP)
Gestational age, behavioral state, HR, O2 sat, brow bulge,
eye squeeze, and nasolabial furrow; often used for
procedural and post-op pain
FLACC Pain Scale
Oucher Pain Scale
Faces Pain Scale
Childrens Coping with Pain
The social context and culture
Previous experience with pain
Cognitions, evaluations, 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

internalize/catastrophize
Piira et al. (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 dont 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
- not necessarily true just need to find a good balance for them
Giving narcotics to children is addictive and dangerous
- yes and no; need to be careful what we give to teenagers; but young
children who have been through surgery or something, thats a
different case
- 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

 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- Grief and Loss

Grief is an inevitable, never-ending process that results from a
permanent or temporary disruprtion in a routine, a separation, or
a change in a relationship that may be beyond the persons
control. This disruption, change, or separation causes pain and
discomfort and impacts the persons thoughts, feelings, and
behaviors. Although loss is a universal experience, the causes
and manifestations of it are unique to each individual and may
change over time.
(Fiorini & Mullen, 2006, p. 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, they show lower
anxiety and greater tolerance/acceptance of less parental
attention
Bereaved children need explanations, comfort, and support
Pretense and avoidance can be frightening to anyone in a
stressful and painful setting, especially a child
If children are involved in grieving of the family, it helps them to

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, headaches, heartaches
Frequent accidents or injuries
Sleep disturbances
Loss of appetite or increased eating
Low energy, 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, or poor quality
Increase in absences
Over achievement, 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, 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

Confusion about what happens after death

Doubting or questioning previous beliefs
Sense of despair about the future
Change in values, questioning of what is important

Factors Affecting Childrens Responses to Death

How the parent died
Religion and culture
Support available
Unfinished business
Characteristics of the child
Childs 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 Doesnt understand the permanence of the loss, will ask for the
missing parent
o May become angry because parent doesnt come back,
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 parents return
o Magical thinking, thoughts about life in the cemetery
o Believes death is reversible
o Clinging to favorite toys
o Can become withdrawn, depressed
o Nightmares, agitated at night
o May ask questions over and over
o Separation anxiety cant 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, but might
not think of own death

o May feel responsible for the death

o Grieving manifest in changes in behavior, school performance,
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, denial, anxiety, distress, anger, depression
o Difficulties concentrating
o Decline in school work
o May complain of physical pains, fatigue, drowsiness
o Become withdrawn, isolated
o Increased risk taking, 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

 Overprotectiveness of the surviving parent

Constructing the deceased parent
William Wordens 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, 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