Abnormal Behavior in Childhood and Adolescence Pauline Cabrera

Abnormal Behavior in Childhood and Adolescence Pauline Cabrera BS Psych IV

Key Concepts • “Behavior” – The way in which a person responds to a specific set of conditions (Microsoft Encarta, 2009)

• “Abnormal” – Unusual or unexpected, especially in a way that causes alarm or anxiety (Microsoft Encarta, 2009)

• “Abnormal Behavior” – includes any activity judged to be outside the normal behavior pattern for animals of that particular class and age, including the vices, the fixed patterns of abnormality. (Medical dictionary. thefreedictionary. com, 2011)

• “Childhood” – Somebody’s earliest years: the state of being a child (Microsoft Encarta, 2009) • “Adolescence” – Time preceding adulthood: the period from puberty to adulthood (Microsoft Encarta, 2009)

Mental Retardation • “Intellectual Disability” – DSM-V • It is a condition diagnosed before age 18 that includes below-average general intellectual function, and a lack of the skills necessary for daily living. (Medline. Plus, 2011)

• Developmental delay – an overly inclusive term and should generally be used for infants and young children (< 5 y) in which the diagnosis is unclear, such as those too young formal testing.

• MR/ID originates during the developmental period (ie, conception through age 18 years) and results in significantly sub-average general intellectual function with concurrent deficits in functional life skills. • The diagnosis of MR/ID requires an intelligence deficit of at least 2 standard deviations (SDs) below the mean IQ. This generally translates into an intelligence quotient (IQ) score of 70 -75, given a population mean of 100. • Equivalent deficits in at least 2 areas of functional life skills or adaptive skills also must be present to meet the diagnostic criteria for MR/ID.

• Adaptive skills encompass functional life skills within the domains of ücommunication, üself-care, ühome living, üsocial and interpersonal skills, üuse of community resources, üself-direction, üfunctional academic skills, üwork, üleisure, ühealth, üand safety.

• Mental retardation affects about 1 - 3% of the population. • Approximately 10% of children have some learning impairment, while as many as 3% manifest some degree of MR/ID. • The population prevalence of these combined disorders of learning rivals that of the common childhood disorder asthma.

• A family may suspect mental retardation if the child's motor skills, language skills, and selfhelp skills do not seem to be developing, or are developing at a far slower rate than the child's peers. • Failure to adapt (adjust to new situations) normally and grow intellectually may become apparent early in a child's life. • In the case of mild retardation, these failures may not become recognizable until school age or later.

Intellectual Disability Categorization

Causes • Infections (present at birth or occurring after birth) – Congenital CMV – Congenital rubella – Congenital toxoplasmosis – Encephalitis – HIV infection – Listeriosis – Meningitis • Chromosomal abnormalities – Chromosome deletions (cri du chat syndrome) – Chromosomal translocations (a gene is located in an unusual spot on a chromosome, or located on a different chromosome than usual) – Defects in the chromosome or chromosomal inheritance (for example, fragile X syndrome, Angelman syndrome, Prader-Willi syndrome) – Errors of chromosome numbers (such as Down syndrome)

• Environmental – Deprivation syndrome • Genetic abnormalities and inherited metabolic disorders – Adrenoleukodystrophy – Galactosemia – Hunter syndrome – Hurler syndrome – Lesch-Nyhan syndrome – Phenylketonuria – Rett syndrome – Sanfilippo syndrome – Tay-Sachs disease – Tuberous sclerosis • Metabolic – Congenital hypothyroid – Hypoglycemia (poorly regulated diabetes) – Reye syndrome – Hyperbilirubinemia (very high bilirubin levels in babies)

• Nutritional – Malnutrition • Toxic – Intrauterine exposure to alcohol, cocaine, amphetamines, and other drugs – Lead poisoning – Methylmercury poisoning • Trauma (before and after birth) – Intracranial hemorrhage before or after birth – Lack of oxygen to the brain before, during, or after birth – Severe head injury • Unexplained (this largest category is for unexplained occurrences of mental retardation)

Symptoms ü Language delay ü One of the first signs-- including expressive language (speech) and receptive language (understanding). ü Red flags include no mama/dada/babbling by 12 months, no 2 -word phrases by age 2, and parents reporting they are concerned that the child may be deaf. ü Fine motor/adaptive delay ü Significant delays in activities such as self-feeding, toileting, and dressing ü Prolonged, messy finger feeding and drooling are signs of oral-motor incoordination. ü Cognitive delay ü have difficulties with memory, problem-solving and logical reasoning. ü This may be expressed early on with preacademic difficulties or difficulty following directions (particularly multipart directions).

ü Social delays ümay display lack of interest in age-appropriate toys and delays in imaginative play and reciprocal play with age-matched peers. ü Gross motor üDelays in gross motor development infrequently accompany the cognitive, language, and fine motor/adaptive delays associated with MR/ID unless the underlying condition results in both MR/ID and cerebral palsy. üSubtle delays in gross motor acquisition, or clumsiness, may be identified in the developmental assessment.

ü Behavioral disturbances ü Even before an age at which psychopathology can be identified, infants and toddlers who go on to have MR/ID may be more likely to have difficult temperaments, hyperactivity, disordered sleep, and colic (excessive crying). ü Associated behaviors may include aggression, selfinjury, defiance, inattention, hyperactivity, sleep disturbances, and stereotypic behaviors. ü Neurologic and physical abnormalities ü Prevalence of MR is increased among children with seizure disorders, microcephaly, macrocephaly, history of intrauterine or postnatal growth retardation, prematurity, and congenital anomalies.

Learning Disabilities • Learning disability is a general term that describes specific kinds of learning problems. A learning disability can cause a person to have trouble learning and using certain skills. (Medicinenet. com, 2011)

Characteristics of Learning Disabled Students - What Kinds of Students Have Learning Disabilities? • Despite their difficulty in certain skill areas, learning disabled students are usually of average or higher intelligence. • Some students with LDs are also gifted.

• Learning disabilities are neurological differences in processing information that severely limit a person’s ability to learn in a specific skill area. • Everyone has differences in learning abilities, but people with learning disabilities have severe learning problems that persist throughout their lives. • Learning disabled people may have difficulty in school or on the job. • Learning disabilities may also impact independent living and social relationships. (Logsdon, 2011)

• Learning disabilities (LD) vary from person to person. • One person with learning disabilities may not have the same kind of learning problems as another person with learning disabilities.

• The skills most often affected are: Reading

Writing

Speaking

Reasoning

Doing math

More signs and symptoms… • may have trouble learning the alphabet, rhyming words, or connecting letters to their sounds; • may make many mistakes when reading aloud, and repeat and pause often; • may not understand what he or she reads; • may have real trouble with spelling; • may have very messy handwriting or hold a pencil awkwardly; • may struggle to express ideas in writing; • may learn language late and have a limited vocabulary; • may have trouble remembering the sounds that letters make or hearing slight differences between words;

• may have trouble understanding jokes, comic strips, and sarcasm; • may have trouble following directions; • may mispronounce words or use a wrong word that sounds similar; • may have trouble organizing what he or she wants to say or not be able to think of the word he or she needs for writing or conversation; • may not follow the social rules of conversation, such as taking turns, and may stand too close to the listener; • may confuse math symbols and misread numbers; • may not be able to retell a story in order (what happened first, second, third); or • may not know where to begin a task or how to go on from there.

Types of Learning Disabilities • Basic reading and reading comprehension are the two broad categories of reading disabilities. Dyslexia is another term by which reading disabilities are known. • Language comprehension and speaking and expressive language are the two main types of language disorders. • Basic writing and expressive writing are the two types of writing disorders. Some diagnostic systems refer to writing disorders as dysgraphia. • Basic math and applied math are the two main types of math disorders. Some diagnostic systems refer to math disorders as dyscalculia.

• Researchers think that learning disabilities are caused by differences in how a person's brain works and how it processes information. • Children with learning disabilities are not "dumb" or "lazy. " • In fact, they usually have average or above average intelligence. Their brains just process information differently.

Disabilities of Learning and Heredity - Are Learning Disabilities Biological? • True learning disabilities (LDs) are believed to be an organic type of disability resulting from neurological processing problems that cause difficulty with learning and applying skills in one or more academic areas. • Evidence suggests that a child's chances of having a learning disability increase when parents or other relatives also have learning disabilities. • This suggests that heredity may play a role in some cases. However, there are other possible causes of LDs that can be prevented in some cases.

Communication Disorders • It involves a wide variety of problems in speech, language, and hearing. (Keller, 2005) • For example, speech and language disorders include stuttering, aphasia, dysfluency, voice disorders (hoarseness, breathiness, or sudden breaks in loudness or pitch), cleft lip and/or palate, articulation problems, delays in speech and language, autism, and phonological disorders.

• Speech and language impairments and disorders can be attributed to environmental factors, of which the most commonly known are High Risk Register problems, which include drugs taken during pregnancy, common STD's such as syphilis, and birthing trauma to name a few. • Communication disorders can also stem from other conditions such as learning disabilities, dyslexia, cerebral palsy, and mental retardation.

Causes • Hearing disorders and deafness – There are two main types of hearing loss. • One happens when your inner ear or auditory nerve is damaged. This type is permanent. • The other kind happens when sound waves cannot reach your inner ear. Earwax build-up, fluid or a punctured eardrum can cause it. – Untreated, hearing problems can get worse. – Possible treatments include hearing aids, cochlear implants, special training, certain medicines and surgery. (Medline. Plus. com, 2011)

• Voice problems, such as dysphonia or those caused by cleft lip or palate – Many things we do can injure our vocal cords. – Talking too much, screaming, constantly clearing your throat or smoking can make you hoarse. – These can also lead to problems such as nodules, polyps and sores on the vocal cords. – Other causes of voice disorders include infections, upward movement of stomach acids into the throat, growths due to a virus, cancer and diseases that paralyze the vocal cords. – Treatment for voice disorders varies depending on the cause. Most voice problems can be successfully treated when diagnosed early.

• Speech problems like stuttering – Stuttering is a problem that affects the flow of your speech. If you stutter, you may ü Make certain words sound longer than they should be ü Find it hard to start a new word ü Repeat words or parts of words ü Get tense when you try to speak. You may blink your eyes rapidly, or your lips and jaw may tremble as you struggle to get the words out – Stuttering can affect anyone. However, it is most common in young children who are still learning to speak. Boys are three times more likely to stutter than girls. Most children stop stuttering as they grow older. Less than 1 percent of adults stutter. – Scientists don't fully understand why some people stutter. The problem seems to run in families. There is no cure, but stuttering therapy for young children can keep it from becoming a lifelong problem.

• Developmental disabilities • Nervous system disabilities affecting how the brain, spinal cord and nervous system function. • They cause mental retardation, including Down syndrome and fragile X syndrome. • They also cause learning and behavioral disorders, such as autism • Sensory-related disabilities, which can cause vision, hearing and sight problems • Most developmental disabilities have no cure, but you can often treat the symptoms. Physical, speech and occupational therapy might help. Special education classes and psychological counseling can also help.

• Learning disorders – People with learning disorders may have problems üListening or paying attention üSpeaking üReading or writing üDoing math

• Brain injury – Symptoms of a TBI may not appear until days or weeks following the injury. Serious traumatic brain injuries need emergency treatment. – Treatment and outcome depend on the injury. TBI can cause a wide range of changes affecting thinking, sensation, language, or emotions. – TBI can be associated with post-traumatic stress disorder. – People with severe injuries usually need rehabilitation.

• Stroke • A stroke is a medical emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die. • There are two kinds of stroke. – The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. – The other kind, called hemorrhagic stroke, is caused by a blood vessel that breaks and bleeds into the brain. • "Mini-strokes" or transient ischemic attacks (TIAs), occur when the blood supply to the brain is briefly interrupted.

Autism • It is a developmental disorder that is characterized by impaired development in communication, social interaction, and behavior.

• It is classified as a pervasive developmental disorder (PDD), a category of disorders that is often described interchangeably with the broad spectrum of developmental disorders affecting young children and adults called the autistic spectrum disorders (ASD). • The range of these disorders varies from severely impaired individuals with autism to other individuals who have abnormalities of social interaction but normal intelligence-Asperger's syndrome. The ways in which autism is exhibited can differ greatly. • Additionally, autism can be found in association with other disorders such as mental retardation and certain medical conditions. The degree of autism can range from mild to severe. Mildly affected individuals may appear very close to normal. Severely afflicted individuals may have an extreme intellectual disability and unable to function in almost any setting.

What are the symptoms of autism? • The current Diagnosis and Statistical Manual of Mental Disorders-Fourth Edition, Treatment Revision (DSM-IV-TR) identifies three features that are associated with autism: 1. impairment in social interaction, 2. communication, and 3. behavior.

1. Individuals with autism fail to develop normal personal interactions in virtually every setting. This means that affected persons fail to form the normal social contacts that are such an important part of human development.

2. • Communication is usually severely impaired in persons with autism. • What the individual understands (receptive language) as well as what is actually spoken by the individual (expressive language) are significantly delayed or nonexistent. • Deficits in language comprehension include the inability to understand simple directions, questions, or commands. • There may be an absence of dramatic or pretend play and these children may not be able to engage in simple age-appropriate childhood games such as Simon Says or Hideand-Go-Seek. • Teens and adults with autism may continue to engage in playing with games that are for young children.

3. • Persons with autism often exhibit a variety of repetitive, abnormal behaviors. • There may also be a hypersensitivity to sensory input through vision, hearing, or touch (tactile). • As a result, there may be an extreme intolerance to loud noises or crowds, visual stimulation, or things that are felt. – Birthday parties and other celebrations can be disastrous for some of these individuals. – Wearing socks or tags on clothing may be perceived as painful. Sticky fingers, playing with modeling clay, eating birthday cake or other foods, or walking barefoot across the grass can be unbearable. • • On the other hand, there may be an underdeveloped (hyposensitivity) response to the same type of stimulation. This individual may use abnormal means to experience visual, auditory, or tactile (touch) input. This person may head bang, scratch until blood is drawn, scream instead of speaking in a normal tone, or bring everything into close visual range. He or she might also touch an object, image or other people thoroughly just to experience the sensory input.

• Children and adults who have autism are often tied to routine and many everyday tasks may be ritualistic. • Something as simple as a bath might only be accomplished after the precise amount of water is in the tub, the temperature is exact, the same soap is in its assigned spot and even the same towel is in the same place. • Any break in the routine can provoke a severe reaction in the individual and place a tremendous strain on the adult trying to work with him or her.

• There may also be non-purposeful repetition of actions or behaviors. • Persistent rocking, teeth grinding, hair or finger twirling, hand flapping and walking on tiptoe are not uncommon. • Frequently, there is a preoccupation with a very limited interest or a specific plaything. A child or adult may continually play with only one type of toy. The child may line up all the dolls or cars and the adult line up their clothes or toiletries, for example, and repeatedly and systematically perform the same action on each one. • Any attempt to disrupt the person may result in extreme reactions on the part of the individual with autism, including tantrums or direct physical attack. Objects that spin, open and close, or perform some other action can hold an extreme fascination. • If left alone, a person with this disorder may sit for hours turning off and on a light switch, twirling a spinning toy, or stacking nesting objects. • Some individuals can also have an inappropriate bonding to specific objects and become hysterical without that piece of string, paper clip, or wad of paper.

Other symptoms in young children include the following: • Avoids cuddling or touching • Frequent behavioral outbursts, tantrums • Inappropriate attachments to objects • Maintains little or no eye contact • Over- or undersensitivity to pain, no fear of danger • Sustained abnormal play • Uneven motor skills • Unresponsiveness to normal teaching methods and verbal clues (may appear to be deaf despite normal hearing)

News on Autism!

Attention Deficit and Disruptive Behavior Disorders • A condition characterized by attention problems and disruptive behavior. • The condition is considered to be a grouping of three other disorders - 1. oppositional defiant disorder, 2. conduct disorder and 3. attention-deficit hyperactivity disorder.

Signs and Symptoms • • • • Impulsivity Distractibility Risk-taking behaviors Difficulties at school Poor social skills Lack of attention Frustration Aggression Difficulty following rules Difficulty completing work Undertaking antisocial behavior Aggressiveness Destruction of property Alcohol use Drug use Truancy

Oppositional Defiant Disorder Children with repeatedly engage in a pattern of defiant, disobedient, and hostile behavior toward authority figures. This behavior goes beyond acceptable misbehavior for the given child's age and the behavior has been continued for at least six months. • Symptoms: – Persistent resistance towards taking direction from others – Stubbornness or non-compliant behavior – An unwillingness to compromise – Frequent arguing with, talking back to, or challenging of authority – Irritability, resentfulness, or negativity – Deliberate provocation of others which comes across as mean, spiteful, or rude – Temper tantrums or outbursts – Externalization of blame (it's always someone else's fault). Always blaming others or denying responsibility – Repeated testing of other people's limits (ignoring orders, arguing with directions) – Repeated trouble at school – Few or no friends

• A child with Conduct Disorder engages in repetitive, persistently deviant, impulsive, and/or antisocial behavior that violates the basic rights of other people, or age-appropriate social norms for expected behavior. • Symptoms: – 1) act aggressively in a way that causes or threatens to cause physical harm to others, – 2) cause serious property damage even if they are not actually aggressive towards other adults or children, – 3) steal, and are deceitful, and/or – 4) frequently violate rules.

• ADHD produces symptoms that are • • • characterized by distractibility, hyperactivity, poor impulse control, and forgetfulness. The "attention deficit" component of ADHD refers to inattention, or difficulty focusing for long periods and being easily distractible. The "hyperactivity" portion of. ADHD is used to describe behavior that is restless, agitated, and difficult to resist. Hyperactive individuals often appear as if they NEED to move. They are in almost constant motion, and frequently make excessive noise. Although impulsivity is not included in the diagnostic label, it is also considered a behavior characteristic of this disorder. When impulsivity is paired with hyperactivity, the person appears to act without prior thought or intention. Impulsive behaviors are often intrusive, rude, and dangerous, sometimes resulting in accidents. For example, children may not think about landing when they jump off a ledge to catch a ball.

• The general symptoms of ADHD include: – – – – – Failure to pay attention or a failure to retain learned information Fidgeting or restless behavior Excessive activity or talking The appearance of being physically driven or compelled to constantly move Inability to sit quietly, even when motivated to do so Engaging in activity without thinking before hand Constantly interrupting or changing the subject Poor peer relationships Difficulty sustaining focused attention Distractibility Forgetfulness or absentmindedness Continual impatience Low frustration tolerance When focused attention is required, it is experienced as unpleasant Frequent shifts from one activity to another Careless or messy approach to assignments or tasks Failure to complete activities Difficulty organizing or prioritizing activities or possessions

• ADHD is Not: – An Attitude Problem - The difficulties associated with ADHD are not due to defiance or getting into a battle about control. Nor are they a sign of laziness or irresponsibility. The behaviors associated with ADHD are chronic and part of the disorder. With help, an individual can learn to manage these behaviors. – A Personality Disorder -ADHD is a neurological disorder that often co-exists with other disorders, including personality disorders. – An Absolute Problem - The impact of the issues surrounding ADHD vary in degree from person to person and are influenced by the environment. Individuals can learn a range of skills to manage their symptoms and their performance can improve with increased stimulation and behavior-specific reinforcement (i. e. , reward) systems (described later). – A Lack of Intelligence - Often, individuals with ADHD are highly intelligent and creative.

• ADHD is: – A non-curable neurological disorder that creates information processing challenges among those individuals affected by it. – In other words, those with ADHD think differently and, at times, less clearly than other people without ADHD. These thought difficulties often lead people to respond differently to events that occur. For example, when a new child enters an ongoing playgroup, most children will notice the newcomer. – However, children with ADHD might not be aware that the peer is new to the group, thinking instead that they didn't notice the peer before (like so many other people and things that suddenly appear in their environment).

Eating Disorders • An eating disorder is marked by extremes. • It is present when a person experiences severe disturbances in eating behavior, such as extreme reduction of food intake or extreme overeating, or feelings of extreme distress or concern about body weight or shape.

• Eating disorders are very complex, and despite scientific research to understand them, the biological, behavioral and social underpinnings of these illnesses remain elusive. • The two main types of eating disorders are anorexia nervosa and bulimia nervosa. • A third category is "eating disorders not otherwise specified (EDNOS), " which includes several variations of eating disorders. Most of these disorders are similar to anorexia or bulimia but with slightly different characteristics. Bingeeating disorder, which has received increasing research and media attention in recent years, is one type of EDNOS.

• Eating disorders frequently appear during adolescence or young adulthood, but some reports indicate that they can develop during childhood or later in adulthood. • Women and girls are much more likely than males to develop an eating disorder. • Eating disorders are real, treatable medical illnesses with complex underlying psychological and biological causes. They frequently co-exist with other psychiatric disorders such as depression, substance abuse, or anxiety disorders. • People with eating disorders also can suffer from numerous other physical health complications, such as heart conditions or kidney failure, which can lead to death.

Anorexia Nervosa

• Anorexia nervosa is characterized by emaciation, a relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight, a distortion of body image and intense fear of gaining weight, a lack of menstruation among girls and women, and extremely disturbed eating behavior. • Some people with anorexia lose weight by dieting and exercising excessively; others lose weight by self-induced vomiting, or misusing laxatives, diuretics or enemas.

• Many people with anorexia see themselves as overweight, even when they are starved or are clearly malnourished. • Eating, food and weight control become obsessions.

• A person with anorexia typically weighs herself or himself repeatedly, portions food carefully, and eats only very small quantities of only certain foods. • Some who have anorexia recover with treatment after only one episode. • Others get well but have relapses. • Still others have a more chronic form of anorexia, in which their health deteriorates over many years as they battle the illness.

• According to some studies, people with anorexia are up to ten times more likely to die as a result of their illness compared to those without the disorder. • The most common complications that lead to death are cardiac arrest, and electrolyte and fluid imbalances. Suicide also can result. • Many people with anorexia also have coexisting psychiatric and physical illnesses, including depression, anxiety, obsessive behavior, substance abuse, cardiovascular and neurological complications, and impaired physical development.

• Other symptoms may develop over time, including: – thinning of the bones (osteopenia or osteoporosis) – brittle hair and nails – dry and yellowish skin – growth of fine hair over body (e. g. , lanugo) – mild anemia, and muscle weakness and loss – severe constipation – low blood pressure, slowed breathing and pulse – drop in internal body temperature, causing a person to feel cold all the time – lethargy

Bulimia Nervosa • Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food (e. g. , binge-eating), and feeling a lack of control over the eating. • This binge-eating is followed by a type of behavior that compensates for the binge, such as purging (e. g. , vomiting, excessive use of laxatives or diuretics), fasting and/or excessive exercise.

• Unlike anorexia, people with bulimia can fall within the normal range for their age and weight. • But like people with anorexia, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. • Usually, bulimic behavior is done secretly, because it is often accompanied by feelings of disgust or shame. • The binging and purging cycle usually repeats several times a week.

• Similar to anorexia, people with bulimia often have coexisting psychological illnesses, such as depression, anxiety and/or substance abuse problems.

Other symptoms include: • chronically inflamed and sore throat • swollen glands in the neck and below the jaw • worn tooth enamel and increasingly sensitive and decaying teeth as a result of exposure to stomach acids • gastro esophageal reflux disorder • intestinal distress and irritation from laxative abuse • kidney problems from diuretic abuse • severe dehydration from purging of fluids

Binge-eating Disorder • It is characterized by recurrent binge-eating episodes during which a person feels a loss of control over his or her eating. • Unlike bulimia, binge-eating episodes are not followed by purging, excessive exercise or fasting. • As a result, people with bingeeating disorder often are overweight or obese. • They also experience guilt, shame and/or distress about the binge-eating, which can lead to more binge-eating.

• Obese people with binge-eating disorder often have coexisting psychological illnesses including anxiety, depression, and personality disorders. In addition, links between obesity and cardiovascular disease and hypertension are well documented.

Elimination Disorders • Elimination disorders are disorders that concern the elimination of feces or urine from the body. • The causes of these disorders may be medical or psychiatric. • The American Psychiatric Association recognizes two elimination disorders, 1. encopresis and 2. enuresis.

Encopresis • It is an elimination disorder that involves repeatedly having bowel movements in inappropriate places after the age when bowel control is normally expected. Encopresis is also called fecal incontinence.

• Medical causes of encopresis are usually related to chronic constipation. • As hard feces build up in the large intestine, the bowel is stretched out of shape. This allows liquid feces behind the hard stool to involuntarily leak out and stain clothing. • Other medical causes of encopresis include malformations of the bowel and side effects of medication. Laxatives (medications that relieve constipation), drugs that kill some of the good bacteria in the intestines, and drugs that increase contractions in the intestines can all cause involuntary encopresis. Pediatricians or family physicians treat almost all cases of encopresis having medical causes. • In cases of prolonged involuntary soiling, children may develop feelings of shame and embarrassment, leading to low self-esteem.

• Psychiatric causes of encopresis are not as clear. • A few children may experience encopresis because of fear of the toilet or because their toilet training was either overly pressured or irregular and incomplete. • Older children may soil intentionally, sometimes smearing the feces on wall or clothing or hiding feces around the house. • Children who show this pattern of soiling behavior often have clinical behavior problems such as conduct disorder or oppositional defiant disorder. • About one-quarter of children who soil intentionally also have enuresis.

Enuresis • It is more commonly called bed-wetting, is an elimination disorder that involves release of urine into bedding, clothing, or other inappropriate places.

• Enuresis also has both medical and psychiatric causes. • Primary enuresis occurs when a child has never established bladder control. Medical causes of primary enuresis are often related to malformations of the urinary system, developmental delays, and hormonal imbalances that affect the ability to concentrate urine. There appears to be a genetic component to primary enuresis, since the condition tends to run in families. Primary enuresis may also be caused by psychological stressors such as family instability or erratic toilet training. • Secondary enuresis occurs when a child has established good bladder control for a substantial period, then begins wetting again. Involuntary secondary enuresis is thought to be brought on by life stresses. • For example, it is common for young children to begin wetting the bed after moving to a new house or having a new sibling enter the family. Voluntary enuresis is not common. Like voluntary encopresis, it is associated with psychiatric conditions such as conduct disorder and oppositional defiant disorder.

• Both of these disorders can occur during the day (diurnal) or at night (nocturnal). They may be voluntary or involuntary. • Encopresis and enuresis may occur together, although most often they occur separately. • Elimination disorders may be caused by a physical condition, a side effect of a drug, or a psychiatric disorder. • It is much more common for elimination disorders to be caused by medical conditions than psychiatric ones.

• In most cases in which the cause is medical, the soiling is unintentional. • When the causes are psychiatric, the soiling may be intentional, but it is not always so.

Sleep Disorders • A sleep disorder (somnipathy) is a medical disorder of the sleep patterns of a person or animal. • Some sleep disorders are serious enough to interfere with normal physical, mental and emotional functioning. • A test commonly ordered for some sleep disorders is the polysomnography.

• There are more than 70 different sleep disorders, which are generally classified into one of three categories: 1. lack of sleep (e. g. , insomnia), 2. disturbed sleep (e. g. , obstructive sleep apnea), and 3. excessive sleep (e. g. , narcolepsy).

• The most common sleep disorders include: – Primary insomnia: Chronic difficulty in falling asleep and/or maintaining sleep when no other cause is found for these symptoms. – Bruxism: Involuntarily grinding or clenching of the teeth while sleeping. – Delayed sleep phase syndrome (DSPS): inability to awaken and fall asleep at socially acceptable times but no problem with sleep maintenance, a disorder of circadian rhythms. (Other such disorders are advanced sleep phase syndrome (ASPS), non-24 -hour sleep-wake syndrome (Non-24), and irregular sleep wake rhythm, all much less common than DSPS, as well as the transient jet lag and shift work sleep disorder. ) – Hypopnea syndrome: Abnormally shallow breathing or slow respiratory rate while sleeping. – Narcolepsy: Excessive daytime sleepiness (EDS) often culminating in falling asleep spontaneously but unwillingly at inappropriate times. – Cataplexy: a sudden weakness in the motor muscles that can result in collapse to the floor. – Night terror: Pavor nocturnus, sleep terror disorder: abrupt awakening from sleep with behavior consistent with terror. – Parasomnias: Disruptive sleep-related events involving inappropriate actions during sleep; sleep walking and night-terrors are examples.

– Periodic limb movement disorder (PLMD): Sudden involuntary movement of arms and/or legs during sleep, for example kicking the legs. Also known as nocturnal myoclonus. – Rapid eye movement behavior disorder (RBD): Acting out violent or dramatic dreams while in REM sleep. – Restless legs syndrome (RLS): An irresistible urge to move legs. RLS sufferers often also have PLMD. – Situational circadian rhythm sleep disorders: shift work sleep disorder (SWSD) and jet lag. – Sleep Apnea, and mostly Obstructive sleep apnea: Obstruction of the airway during sleep, causing lack of sufficient deep sleep; often accompanied by snoring. Other forms of sleep apnea are less common. – Sleep paralysis: is characterized by temporary paralysis of the body shortly before or after sleep. Sleep paralysis may be accompanied by visual, auditory or tactile hallucinations. Not a disorder unless severe. Often seen as part of Narcolepsy. – Sleepwalking or somnambulism: Engaging in activities that are normally associated with wakefulness (such as eating or dressing), which may include walking, without the conscious knowledge of the subject. – Nocturia: A frequent need to get up and go to the bathroom to urinate at night. It differs from Enuresis, or bed-wetting, in which the person does not arouse from sleep, but the bladder nevertheless empties. – Somniphobia: a dread of sleep.

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