The focus of this study will be the lived experience of women suffering from Multiple Sclerosis and their ability to maintain a quality of life through various coping strategies. Therefore, literature surrounding the quality of life and coping mechanisms in MS sufferers will be critically appraised.

A literature review was performed to identify published material relating to the lived experience of women suffering with MS with the main focus being on how women cope with the challenges that MS brings everyday and how they try and maintain a quality of life. This was done to introduce the topic of interest. When conducting the research there was little research into this area but the search was limited to health and social care databases such as CINALH, Internurse, Science direct, Pubmed and the library catalogue. The key words that were initially used in the literature search were lived experience, multiple sclerosis, women and quality of life and coping mechanisms, however this revealed little research so key words such as fatigue, education and depression were included.

2.1 Emotional Responses in Multiple Sclerosis

2.1.1 Uncertainty

Uncertainty is one of the first stresses that MS places on women. First there is uncertainty until the diagnosis has been confirmed. Having MS means living with uncertainty and adapting to changing situations with the course of MS. Being unpredictable posses an emotional challenge to build a sense of stability and security in the face of uncertainty (Halper & Holland, 1997). Miller’s (1997) phenomenological study emphasized the primary role of uncertainty in the lived experiences of patients with relapsing MS. The participants in this study are described as living one day at a time, not knowing how they will feel tomorrow, leading to negative effects on employment, family life and coping abilities. It was also evident that fear and loss of control in daily life were also experienced due the unpredictability of relapsing MS. Olsson, Lexell & Soderberg (2007) conducted a qualitative in order to describe the meaning of women’s experience of living with MS. The study consisted of 10 women with secondary progressive MS and the fact that daily life was influenced by MS. Women spoke about their daily life’s, their experience of symptoms and their thoughts about their illness. They described that they were no longer in charge over their body and this had a great impact on their quality of life, however, women were found to actively strive to maintain strength and power to carry on to protect their dignity. This study showed that people with the progressive form of the disease appeared to cope better and were determined to improve their quality of life despite the effects of the illness, this could be due to them accepting MS as part of their life.

2.1.2 Hope

Hope relates to those things that can be realistically achieved (Pinson, Ottens & Fisher, 2009). This implies that the individual has devised a plan that has the likelihood of being carried out to achieve resolution of a problem. Miller (1997) found that hope provided a means for dealing with the uncertainty of MS. In a quantitative study carried out by Goretti, Pataccio, Zipoli, Hakiki, Siracusa, Sori and Amato (2009) they found that women tend to have higher levels of hope and optimism when facing the disease at early stages. Their study looked at the psychological features of depression, fatigue and anxiety, coping strategies and their influence on quality of life in people suffering from remitting relapsing MS. , furthermore, a qualitative study by Pinson et al (2009) found that hope was present as a coping resource. Also, hope seems to interact with psychosocial resources such as self-esteem, hope has often been related to higher levels of self-esteem and evidence of better social support. However, Pinson et al (2009) study only focused on people with a progressive form of MS and who did not suffer with depression. Depression itself can have a significant affect on a individuals self-esteem, if a MS sufferer as lowered self esteem due to depression then their coping mechanisms will be compromised and this will contribute to a lower quality of life perception ( Murphy, 1998).

2.2 Information and education

Multiple Sclerosis considerably changes peoples every day life and the power and capacity to meet personal expectations (Yorkson, Klasner & Swanson, 2001). Toombs (1995) stated that living with MS implies insecurity on a daily basis as their body can not be taken for granted or trusted, instead, it demands constant attention. To manage every day life, people with MS find it urgent to prioritise their personal goals and the search for information and knowledge regarding the disease has been described as crucial in maintaining control. A qualitative study carried out by Fleming Courts, Buchanan and Werstlein (2004) investigated the lived experience of people with MS and examined their needs from their perspectives using two focus groups consisting of 4 men and 6 women, they found that education is power and having education about the disease helps whose in maintaining a quality of life, without knowledge, information and education from health care professionals about the disease, its symptoms and what support is available then coping with daily activities will be compromised and a good quality of life will not be achievable. Miller (1997) and Pinson (DATE) are supportive of this but conclude that people with MS need information to deal with the uncertainty and the unpredictability of the disease in order to remain in control of their life’s.

2.3 Coping

Coping is an abstract concept that refers to how individuals make meaning and values and can be see as a way of problem solving. Psychological as proved to be crucially important for adjusting to the adaptive demands of the chronic illness and in the past few years as received a growing interest in MS. A study conducted by McCabe, Stokes and McDonald (2009) evaluated the relationship between quality of life and coping among people with MS over a 2 year period using a longitudinal approach. The sample consisted of 144 men and 238 women. The World Health Organisation quality of life scale was used to assess participants overall quality of life. They found that people with MS experienced lower levels of quality for independence, social, environmental and spiritual quality of life but experienced a higher psychological quality of life and focused on positive coping compared to the general population, these findings may suggest that although people with MS have lower levels of quality of life in many areas, they may be more accepting of the situation and knowing that their condition is going to change.

However, in a quantitative carried out by Goretti et al (2009) found that MS patients were less likely to use positive and problem focused strategies and often adopted avoiding strategies more frequently, it was also found that younger patients with relapsing remitting MS were less disabled so therefore the disease had a lower impact on their quality of life, also, positive attitude and planning activity strategies were less likely to be adopted by patients with lower disease duration. They tended to have higher levels of hope and optimism when facing the disease at its early stages. Those who adopted avoiding strategies were more likely to experience depression and anxiety that contributed to their overall quality of life.

2.4 Support

Pinson et al found that knowing family and friends would provide support either emotional or physical was very important to the participants. This support system appears to act as an anchor for these women if situations became difficult.

McCabe also found that when people were more accepting of the situation, there was an increased need for social and emotional support., they also found that women with MS compared to men were more likely to seek social support, but more likely to wish that things were different. This is also supported by Olsson and Goretti. However, Olsson (2008) also found that accepting needing support from family led to feelings of guilt and failure as they felt that the whole family was suffering too. They also described being dependant on others when performing daily tasks that they wished to have done themselves. To engage in daily life was crucial in maintaining a good quality of life. This study only focused on women with the progressive form of MS, so are more likely to have more disabilities. McCabe states that increased needs may lead them to seek and obtain more social support and rely more on friend, family and community assistance (Murphy, 1998). Although support is

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Orem’s Model of Nursing and Leininger’s Cultural Care Diversity Theory

Dorothea Orem and Madeleine Leininger are nurse theorists who made an impact by providing awareness of patient’s autonomy in personal care and culture awareness.  Orem’s Model of Nursing is based on the human adaptation model. This model is based on the expanding movement in psychology that showcases human experiences as ideal, or the principle of human nature that showcases the fact that humans have a full purpose.  They described the systems as being made different complex systems that are used for a greater ideal, not simply just a reason.  Henderson’s Self-Efficacy Theory showcases how individuals can behave.  Henderson’s theory viewed the process that consists of assessment, nursing diagnosis, outcome, planning, implementation, and evaluation as the best approach to a patient’s problem. This paper will showcase the theories while showing just how much they made an impact.

In the late 1950s, Madeleine Leininger identified transcultural nursing, and well into 1980, she presented the transcultural health model. The Leininger Sunrise Model was first described in 1984 and showcases the variety of cultural interviews, tools, and therapeutic means. This theory enlightened nurses to the need of considering the impact of cultural beliefs on the health and well-being of the patient. She had a fundamental influence regarding the concept of nursing is synonymous with caring.  Her pediatric nursing experience and her assessment of the notion of adaptation helped her create this theory.  She written that the resilience of children, a major impact of her adviser, Dorothy Johnson, and the use of von Bertalanffy’s system theory were the guidelines for the 1964 Adaptation Model structure. (McEwen & Wills, 2014). The process of changes to the environment and their responses were also examined.

Henderson created the Self-Efficacy Theory and derived from her practice of nursing and educational activity. Virginia Henderson created significant principles to guide the 20th century’s most effective nursing science growth.  She described the major roles of the nurse as a backup system, that is distinct and complimentary, with the aim of helping a person become as independent as possible.

Orem stated that any particular theorist provided the basis for the Self-Care Deficit Nursing Theory (SCDNT). She showed interest in multiple theories, however she references only Parsons’ structure of social action and von Bertalanffy’s system theorirs. Taylor, Geden, Isaramalai, and Wongvatunyu, however, said that the ontology of Orem’s SCDNT is the foundation of realism, and that the focus is on the person. The SCDNT is a fully developed educated theory system of nursing. Presently, the theory is known to as self-care science and nursing theory. Taylor and Renpenning argue for Orem’s magnum opus and cite widely from her works for the science basis of life work. In Orem’s theory, veritivity examines four aspects of society: the meaning of life, the shared purpose of humanity, the purpose of human existence, and activity and creativity for the common good.  According to this theory, people share a common destiny to make sense of mutual relationships with other people, the world, and God (McEwen & Wills, 2014).  Everyone has a personal and unique identity that is unlike anyone else.  Roy think that nurses add to the common good of society through the use of their knowledge and how they care for the patient.

Henderson thought that basic needs were needed in order to survive (Ahtisham & Jacoline, 2015).  Included in those needs were the need to eat and drink, delete the body of toxins, sleep, and to keep the body clean.  Self-efficacy of an individual refers to maintaining physiological and emotional balance (Ahtisham & Jacoline, 2015).  For a person to be whole, the mind and body have to be one.  The importance of basic human needs is the foundation of the nursing practice.  This foundation has led to the development of the theory regarding the needs of the patient and the role of the nurse to help meet these needs (Ahtisham & Jacoline, 2015).  The nurse operates as a replacement for this individual’s incapacity to maintain the wholeness or independence of the patient when severe illness occurs in the life of a person.

There are some major assumptions about these theories. First off, Orem’s theory has stayed intact for the most part, but the theory has changed somewhat to adapt to the times. Self-care, self-care deficit, and the nursing system are the three theories that are focused on the most. Orem showcased the theories as an art form in which the nurse gives specialized care and attention to the patient to allow them to meet their need for self-care. Leininger also showcased her theory to help promote health and healing. Her model, however, was to introduce cultural impact on the healing of the patient.

The patient is the whole being, who changes and adapts to their surroundings.  A person strives towards biological, psychological, and social adaption (McEwen & Wills, 2014).  The environment consists of their surroundings and how they behave as either an individual or in a group setting. Health is described as the health-sickness continuum, which goes from the apex of health to dying.  It is the strategy for being a whole person. The target of nursing is to guarantee, advance, and upgrade prosperity, keep away from harm, and simplicity suffering through assurance and treatment of patients, propelling the prosperity of individuals and social requests. There are four adaptable modes, physical, character, part work, and interdependency; conduct in one territory may have an effect for one or the various modes (McEwen & Wills, 2014).

In Henderson’s hypothesis, the idea of self-adequacy is critical to affecting wellbeing conduct change. The body will dependably request change when there is something strange. It is the attendants’ undertaking to attempt to keep up change calm and help patients through at all times, driving them and managing them. Medical attendants do this by offering help and data. Beside attempting to discover a parity in the majority of Henderson’s fourteen parts the attendant ought to likewise attempt to limit the pressure that the patient is experiencing. By doing this, the attendant will assist patients with relaxing and have a clearer personality and an improvement in wellbeing conduct. A few activities that the medical attendant should mull over to connect any hole that may exist between Henderson’s announcement and self-viability could be the utilization of verbal influence when attempting to address the issues of patients just as rehearsing pressure the executives (Ahtisham & Jacoline, 2015).   This will help decrease certain wellbeing practices and frames of mind that may increment with any ailment, ailment, or condition. Individuals are the patients and families that expected help to accomplish the fourteen fundamental needs. The earth in the hypothesis is the natural, physical, and social parts affecting the prosperity of a patient. Wellbeing is viewed as the freedom of self-care for an individual. Nursing practice is gone for helping the patient in performing exercises that will upgrade recuperation. The scholar makes an accentuation on the significance of advancing wellbeing and avoiding illness in light of the fact that ideal wellbeing isn’t constantly feasible for everybody.

Leininger’s Cultural Care Diversity and Universality Theory is one that is strongly impactful throughout nursing.  Real ideas of the model are culture, culture care, and culture care contrasts (decent varieties) and similitudes (universals) relating to transcultural human consideration. Other significant ideas are care and minding, emic see (language articulations, recognitions, convictions, and routine with regards to people or gatherings of a specific culture as to specific marvels), etic see (all-inclusive language articulation convictions and practices as to specific wonders that relate to a few societies or gatherings), lay arrangement of medicinal services, proficient arrangement of human services, and socially consistent nursing care.

Nursing in the United States has a cultural impact every day from around the world. Nurses make a vow to think about patients and this is all around clarified in Henderson’s announcement. Henderson’s meaning of nursing is, for the most part, focused on how the medical attendant should meet each patient needs in connection to the fourteen segments (Ahtisham and Jacoline, 2015). Attendants will be at the bedside of patients, being far-reaching and seeing every minute that they experience, just as their relatives. Medical attendants will talk up when they are not ready to, and attendants will loan them a hand when they don’t have one. Medical attendants will attempt to keep up their self-viability and wellbeing conduct at a larger amount (Ahtisham and Jacoline, 2015). It is clear how the medical caretaker completes her undertakings to help the customer in gathering his or her needs. These requirements might be physical, passionate, social or some other needs. This is accomplished by the medical caretaker by tending to the patient’s capacity to breath typically, eat and drink enough, and dispose of body wastes.

One concept in Roy’s Adaption Model is that to cope with a problem, a patient will use learned coping mechanisms, which may be social, psychological, or biological, in order to cope with a changing world (Perret, 2016).  For example, a patient that uses drugs does so to help eliminate their mindset from a previous trauma.  This patient is using a learned coping skill to cope with a mental issue. Another concept in this model is that a person’s adaptation is a function of both their adaptation level and the stimulus to which they are exposed (Perret, 2016).  In rehab centers, patients have adopted certain coping skills as a result of their ability to cope with a stressful situation and the drug use that they have been doing.  It is the nurses’ duty to enlighten the patient on other coping skills and showcase healthy behaviors, such as a nutritious diet, exercise, and positive groups (Perret, 2016).

According to Henderson, increasing a patient’s independence diminishes a decline in the patient’s health. The nurse’s role when applying this theory focuses on substitutive, supplementary, and complementary care. Substitutive care is when the nurse is doing for the patient, supplementary is when the nurse is helping out the patient, and complementary care is when the nurse is working with the patient with the goal of getting the patient back to a level of independence. Application of Henderson’s theory to nursing follow, therefore, involved that nurses perform to help patients in playacting activities of daily living.  This side particularly refers to those patients World Health Organization are disabled and have limitations in their ability for self-efficacy.

This writer’s perception of Roy’s theory is that it’s a good vary of applications within the nursing field.  She is in a position to use this daily in her observe. for example, addiction affects the physical mode of a patient by resulting in dependence and withdrawal.  This can, in turn, have an effect on the self-concept mode associated with that behavior.  The patient feels guilt and shame as a result.  Addiction additionally affects the role perform mode in this the patient loses their ability to effectively do their life roles as kid, parent, or worker.  Lastly, addiction may be a family un-wellness, poignant the reciprocity mode.  By that specialize in effective management of withdrawal and fascinating the patient in individual, group, and group psychotherapy, nurses are able to bring harmony to all or any these modes and move the patient forward on the health time (Perret, 2016).

In this writer’s current observe, Henderson’s theory is enforced through the utilization of home health for nursing, physiotherapy, and physiatrist till the patient will perform activities of daily living with very little or no help (Ahtisham & Jacoline, 2015).  As a nurse, one ought to be able to place himself or herself within the patients’ shoes.  The nurse has to work by the aspect of the patient and be willing to fastidiously hear the patient’s requirements and preoccupations (Nicely & DeLario, 2014).  The nurse UN agency is that the member of the work team who spends the foremost time on the aspect of the patient is liable for yielding with the orders of the doctors, however the individual attention nurses provide to patients should be within the very best approach supported information, skills and needs to realize patient recovery.  Also, the implementation ought to be supported physiological principles, age, cultural background, emotional balance, and physical and intellectual talents (Ahtisham & Jacoline, 2015).

Orem’s SCDNT is complicated. It consists of 3 nested theories, several presuppositions, and propositions in every of the individual theories. Revisions of the idea from the first model have improved the organization; but, its quality has augmented in response to social wants throughout the many editions. Roy’s Adaptation Model describes folks as being a part of a holistic adaptive system in constant interaction with internal and external environments.  Henderson’s Self-Efficacy Theory has overviewed the thought of self-efficacy as vital to influencing health activity amendment.

For a nurse in any space of care, the tasks of serving to patients to adapt to wherever they’re on the health-illness time are vital.  Roy’s Adaptation Model is a good conjectural framework to deal with multiple problems in nursing observe, similarly as facilitate the method of adaptation to the ever-changing health standing in patients with chronic diseases.  Roy’s Adaptation Model focuses on however the individual responds to the stimuli or forces from the external setting.  Roy additionally mentions the inner world and private values inside her model to demonstrate however adaptation is integrated with health.  Roy’s Adaptation Model theory offers the conjectural framework applied to all or any levels of nursing observe addressing ever-changing health standing.  Henderson’s thought of self-efficacy is sureness and also the conviction of having the ability to succeed in any goal that non-public functions. once a nurse is self-efficacious, one can continually give higher health care to patients, can have a more robust relationship of skilled respect towards colleagues and alternative team members, and, therefore, bigger success in business life.  The nurse will bridge the gap between Henderson’s postulates and self-efficacy by unendingly seeking skilled advancement, rising skills and information, and providing the most effective care to patients.

References

• Ahtisham, Y. & Jacoline, S. (2015). Integrating nursing theory and process into practice; Virginia’s Henderson need theory.
  
  International Journal of Caring Sciences, 8
  
  (2), 443-450.
• McEwen, M., & Wills, E. M. (2014).
  
  Theoretical basis for nursing
  
  (4th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
• Nicely, B., & DeLario, G. T. (2014). Virginia Henderson’s principles and practice of nursing applied to organ donation after brain death.
  
  Progress in Transplantation
  
  ,
  
  21
  
  (1), 72-77.
• Perret, S. E. (2016). Review of Roy adaptation model-based quantitative research.
  
  Nursing Science Quarterly
  
  ,
  
  20
  
  , 349-356. doi.org/10.1177/0894318407306538

This paper examines the prevalence of poor sleep latency, duration, and fragmentation in children diagnosed with autism. It explains the possible causes of sleep disturbances, and its effects on the child and families’ wellbeing. It explores studies that support the use of melatonin, provides instructions for proper use, and explains the limitation of studies presented as well as provides ideas for further research.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder associated with deficits in social and communication skills, stereotypical behaviors and limited interests (American Psychiatric Association 2000). Children with autism are at a higher risk of sleep disorders. Studies report that about 40-80% of children with autism have sleep difficulties.(Giannotti, Cortesi, Cerquiglini, & Bernabei, 2006) The most frequently reported issues in children with autism are sleep latency, difficulty falling asleep, sleep duration, a short amount of sleep and fragmentation, difficulty staying asleep. However, bed time resistance, insomnia, parasomnia, sleep disordered breathing, morning rise problems, and day time sleepiness are all common challenges.

Sleep difficulties negatively affect both children diagnosed with autism and their families. Children with autism sleep and average of 17-43 minutes less than other children their age (Cavalieri, 2016). Lack of sleep is one of the major distresses for families and the most frequently reported challenge faced by parents. Parents of children with autism who have sleep disturbances report more elevated levels of stress than parents of children with ASD, but without sleep difficulties(Giannotti, Cortesi, Cerquiglini, & Bernabei, 2006).

There is a strong association between sleeping difficulties in children with autism and their ability to function during the day. Studies have shown that childhood sleep disturbance have a great bearing on a child’s overall welfare(Cavalieri, 2016). Sleep disturbance effects a child’s health, behavior, attention, cognition, and school performance. Children diagnosed with autism and characterized as having sleep complications were significantly more physical aggressive, irritable, inattentive and hyperactive when compared to children diagnosed with autism alone. Sleep disturbance may increase core and related symptoms of autism. Intervention that are aimed at reducing sleep issues not only improve the child’s health and family life but also may reduce symptoms related to autism(Mazurek & Sohl, 2016).

The etiology of sleep issues in children with ASD is not fully understood. Different theories are currently being studied by scientist. One hypothesis is that disturbance of the circadian rhythms, as observed in children with ASD, might be due to the anomalies in the creation of melatonin. Studies have revealed that children with autism have low levels of nocturnal melatonin which might be credited to the lack of the ASMT gene which creates the enzyme involved in melatonin synthesis(Mazurek & Sohl, 2016).

Another hypothesis suggested is that synaptic plasticity, neurons which support the attainment of complex skills, seems to be affected in autistic individuals. Although autistic children use specific signal processing and exhibit repetitive responses to stimuli they are familiar with, their capacity to learn new skills is impaired. This may be that due to the atypical physiology and sleep problems in autism. Specifically, sleep fragmentation may lead to less connectivity which could hinder neural substrate from creating a distinctive pathways to process information(Doyen, et al., 2011).

In 1994 Melatonin therapy for children with neuro developmental disorders and continuing sleep difficulties was first introduced in the USA. Melatonin is a an over the counter, nutritional supplement that has become popular by parents of children with autism. Melatonin is a neurohormone recognized for regulating circadian and seasonal rhythms. Most of body’s melatonin is generated and secreted by the pineal gland in the brain. The circadian rhythm for the release of melatonin is coordinated with typical sleeping hours. Melatonin induces sleep by inhibiting the wakefulness generating system. Melatonin secretion gradually increases during the night, and steadily decreases during the second half of the night. Melatonin regulation may be abnormal in children with ASD; daytime elevation, decreased amplitude and lack of nighttime elevation have been noted. Specifically, it has been suggested that a later peak in the night of melatonin secretion may be responsible for sleep onset problems, while reduced rhythm amplitude may be related to night awakenings and early morning awaking(Giannotti, Cortesi, Cerquiglini, & Bernabei, 2006).

Although melatonin is not FDA approved, many studies examining the safety and efficacy of melatonin for children with neurodevelopmental delays have exhibited promising results. A meta- analysis of nine- double blinded, randomized, placebo controlled trails, examining 183 patients with intellectual disabilities, all participants exhibited a reduction in sleep latency by an average of 34 min and an increase in sleep time by an average of 50 min(Braam, et al., 2008). Additionally, five randomized double blind placebo controlled studies showed that sleep duration was increased significantly and sleep latency was significantly decreased in children and adolescent with developmental disorders(Doyen, et al., 2011). Six studies examining children with developmental disabilities reported statistically significant decrease in sleep latency from 22 min to 1 hour and 30 min and improvement in daytime behaviors(Garstang & Wallis, 2006, Gringras, et al., 2012, Malow B. , et al., 2011, Wasdell, Bomben, Freeman, Tai, & Weiss, 2008, Wright, et al., 2011). Five of those studies found melatonin to increase total sleep time from 20min to 1hour and 20 minutes in children with neurodevelopment disorders. The more severe the sleep problems the more favorable treatment outcome(Gringras, et al., 2012). In fast release synthetic melatonin, a full dose is released into the blood stream at once, and is s more useful in improving sleep onset delay. While controlled release melatonin, which mimics the body’s natural release of melatonin throughout the night, is more effective for nocturnal awakenings. Current studies have exemplified the success of using both the fast release and the controlled release in promoting and maintaining sleep in children with autism(Giannotti, Cortesi, Cerquiglini, & Bernabei, 2006). Assessing the long term effectiveness of melatonin; when melatonin was discontinued for some children treatment benefits were maintained for 12 and 24 month afterwards. Whereas other children, returned to the pre-treatment baseline. However, when melatonin was reinstated, it was once again effective(Cavalieri, 2016).

An improvement in mood and day time behavior was reported by the parents of children taking melatonin. Using standardized checklist parents reported significant reduction in attention- deficit hyperactivity, stereotyped, and compulsive behaviors(Malow B. , et al., 2011). Children improved mood, calmer demeanor, decreased irritability was attributed to better sleeping patterns. Significant improvement in depression, anxiety and withdrawal symptoms was exhibited during melatonin treatment in children Asperger syndrome. However, no improvement in the scores of Children Autistic Rating Scale ( CARS) were noted(Giannotti, Cortesi, Cerquiglini, & Bernabei, 2006).

Melatonin is effective at amounts as low as .5 to 1mg. The most common quantity used was 2.5- 5mg. All studies started with low doses and raised the dose steadily. Maximum safe and effective dose used in studies was 15mg. On average the medication was dispensed 30 min to 1 hour before bedtime. Although side effect were hardly reported they can consist of; headaches, tiredness, dizziness, confusion , nausea, and tachycardia. However, most studies that used high purity melatonin no side effects were evident. After 6 weeks, or once a sleep cycle is established it is best practice to discontinue using melatonin even though long term use seems safe and may be required. Children whose understanding of environment is so impaired periodic melatonin treatment might be necessary throughout their lives. (Malow B. , et al., 2011)

Much of existing research that studied sleep intervention in children with ASD has limitations. A small number of studies inspected the effectiveness of melatonin using thorough methodologies such as randomized, placebo control and blinded participants and providers. Most studies enrolled a heterogeneous population in term of age, sleep issues and co- morbidities. Greater sample sizes that study a more homogenous groups of children with autism with extended follow up time after the intervention is needed(Doyen, et al., 2011). Examination of the long term effects of melatonin treatment is required. Future longitudinal research is required to thoroughly examine predictors, benefits, and consequences (Doyen, et al., 2011). The long term side effects of taking melatonin on a daily basis on the endocrine system is important. (Leu, Beyderman, Surdyaka, Wang, & Marlow, 2011).

Additional research understanding the sleep process and the causes of sleep disorders in children with autism is needed. A more definite explanation of sleep problems would help providers and parents have more clarity in identifying better treatment options and creating a better plan of care.(Cavalieri, 2016). Doyen, et al., 2011, in his study reports that the mean onset of sleep disturbance is 17 months and mean age of regression for children with autism is 22 months, suggesting that there is a higher vulnerability during this period of life. Further studies concerning the importance of sleep in babies and its effects on their development and behavior would be enlightening.

Melatonin is easily accessible, cheap and has not shown to have any significant side effects. The benefit of using Melatonin as a treatment to increase sleep latency, duration, as well as daytime behaviors in children with autism is clearly demonstrated. Additional research, with greater sample sizes, targeting children with autism, and looking at long term benefits and consequences is needed to further validate Melatonin’s benefits. However, to provide a more global perspective, a comprehensive understanding of the sleep process and its effects on children with autism is required.

References

• American Psychiatric Association. (2013).
  
  Diagnostic and Statistical manual of mental disorders
  
  (5th ed.). Washington, DC: American Psychiatric Association.
• Braam, W., Didden, R., Maas, A., Korzillus, H., Smits, M., & Curfts, L. (2008). Exogenous melatonin for sleep probloms in individuals with intellectual disability: a meta- analysis.
  
  Developmental Medical Child Neurology, 51
  
  , 340-349.
• Cavalieri, A. (2016). Sleep Issues in Children with Autism Spectrum Disoerder.
  
  Pediatric Nursing, 42
  
  , 169-188.
• Doyen, C., Mighiu, D., Kaye, K., Colineaux, C., Beaumanoir, C., Mouraeff, Y., . . . Contejean, Y. (2011). Melatonin in childrne with autistic spectrum disorders: recent and practical data.
  
  Child Adolescents Psychiatry, 20
  
  , 231-239.
• Garstang, J., & Wallis, M. (2006). Randomized Controlled trail of Melatonin for Children with Autistic Spectum Disorder and Sleep Probloms.
  
  Child: Care Health, and Development, 32
  
  (5), 585-589.
• Giannotti, F., Cortesi, F., Cerquiglini, A., & Bernabei, P. (2006). An open label study of controlled- release melatonin in treatment of sleep disorders in children with autims.
  
  Autims Developmental Disorders, 36
  
  , 741-752.
• Gringras, P., Gamble, C., Jonas, A., Wiggs, L., Williamson, P., Sutcliffe, A., & Appleton, R. (2012). Melatonin for sleep problom in children with neurodevelpmetl disorders: Randomised double masked palacebo controlled trail.
  
  BMJ
  
  , 345.
• Leu, R. M., Beyderman, L., Surdyaka, K., Wang, L., & Marlow, B. (2011). Relation of Melatonin to Sleep Architecture in Children.
  
  Autism Developmental Disorders, 41
  
  , 427-433.
• Malow, B., Adkins, K. W., McGrew, S. G., Wang, L., Goldman, S. E., Fawkes, D., & Burnette, C. (2011). Melatonin for sleep in children with autism: A controlled trail examinig dose, tolerability, and outcomes.
  
  Autism Developmental Disorders, 42
  
  , 1729-1737.
• Malow, B., Adkins, K., Reynolds, A., Weiss, S., Loh, A., Fawkes, D., & Clemons, T. (2014). Parent based sleep education for chidren with autism specturm disordrs.
  
  Journal of Autism and Developmental Disorder, 44
  
  (1), 216-228.
• Mazurek, M., & Sohl, K. (2016). Sleep and behavioral probloms in childrn with autism spectrum disorder.
  
  Autism Developmental Disorder, 46
  
  , 1906-1915.
• Wasdell, M., Bomben, M., Freeman, R., Tai, J., & Weiss, M. (2008). A randomized placebo- controlled trail of controlled release mealtonin treatmen of delayed sleep phase syndrom and impaired sleep maintenance in children with neurodevelopmental disabiliiteis.
  
  Journal of Pineal Reserch, 44
  
  (1), 57-64.
• Wright, B., Slims, D., Smart, S., Alwazeer, A., Alderson-Day, B., Allgar, V., & Miles, J. (2011). Melatonin versus placebo in children with autims spectrum condition and sever sleep probloms not amenable to behavior mangement strategies: A randomised controlled crossover trail.
  
  Journal o fAutim and Develpmemtal disorders, 41
  
  (2), 175-184.

CBT and College Drinking

This study would like to identify the dynamics of college drinking and identify the best therapy for intervention as Cognitive Behavior Therapy (CBT).  The purpose is to identify students who drink from Freshman through Senior year and promote a therapy like approach.  Transition to college from high school can be a challenging phase.  Higher expectations for schoolwork, making new friends and being without the parents may increase anxiety, which could present a difficult transition period during freshman year (Budny, 2004).  This kind of transition is often associated with risky behavior such as excessive alcohol consumption (Lorant, 2013).  CBT may be helpful to treat substance abuse and addiction (Davies, 2018).  Alcohol Use Disorder (AUD) is defined by alcohol often taken in

larger amounts

or over a longer period than was intended (American Psychiatric Association, [APA], 2013).

Literature Review

Drinking Habits

Studies have investigated the factors that influenced the onset of binge drinking in college (Weitzman, Nelson, & Wechsler, 2003).   The research, which was based on self-reported responses from students, revealed that most college students are influenced by their environment to start drinking (Weitzman, 2003). Students reported they drink when they are in social surroundings where alcohol is cheap and easily accessible (Weitzman, 2003).  The study also showed people who start binge drinking in college reported inflated definitions of binge drinking (Weitzman, 2003).  Creating a substance-free environment is ideal for limiting the adoption of binge drinking activities (Weitzman, 2003).

Freshman Year Drinking

The first 6 weeks of freshman year are a vulnerable time for underage college drinking and alcohol-related consequences because of student expectations and social pressures at the start of the academic year (National, 2019).  A study explored the possibility of students starting to binge drink before going to college (White and Swartzwelder, 2009).   Most students bring unhealthy drinking habits to college (White, 2009).  Coping with a stressful event is a result that 88.5% of students are using alcohol in Freshman year (American Addictions Centers, 2019).  Alcohol education and prevention programs should target students prior to their arrival on college campuses (White, 2009).  Many students are now required to attend brief alcohol interventions incorporated into freshman orientation (Taylor, 2015).  A study examined the motivations for binge drinking among college students as they transition from the first year to their final year (Wolburg, J.M., 2016).  The study revealed that the need for social validation motivated students to engage in binge drinking (Wolburg, 2016).  Other drinkers use it as a method to enhance transformation from childhood to adulthood (Wolburg, 2016).  Avocation is needed for increased behavioral therapies during freshmen and sophomore years (Wolburg, 2016).

Sophomore Year Drinking

Heavy consumption during the earlier years is consistent with pregaming and other binge styles of drinking that are more typical of underage drinkers. (Wolburg, 2016).  Sophomore year students may mature slightly stating it’s more about bonding with your group of friends (Wolburg, 2016).  Compared to Freshman year drinking to cope with a stressful event decreased (-3.9%) as a Sophomore to 84.6% (American, 2019).  Sophomores are more confident now that they have experienced one full year of college life.  Some Sophomores will transition from drinking in the dorms to bars because students have fake IDs by the time they became sophomores (Wolburg, 2016).

Junior Year Drinking

Students generally reach the legal drinking age as a Junior.  After students turn 21, they have easier access to alcohol and they may not feel as compelled to pre-party as when they had more limited, illegal access (Wolburg, 2016).   Junior year provides the move from dorms to apartments or houses and changes the ordering function of drinking, freedom from rules and the ability for juniors to host the house parties that freshmen attend seeking easy access to alcohol (Wolburg, 2016).  Junior year found an increase (93.3%) in alcohol to cope with a stressful event (American, 2019).  This may be due to new pressures to cope with internships, job searches and advanced classes, etc. (Rabalais, 2015)

Senior Year Drinking

The transition from Junior to Senior year is more subtle than other transitions. (Wolburg, 2016).  The transformation reflects students’ awareness that they will soon graduate and move into the world beyond college (Wolburg, 2016).  Many students agreed that by their Senior year they drank less, this is my last year of college, drinking is not one of my priorities (Wolburg, 2016).  The maturity factor brings about reduced drinking for many students, the need to make the most of the remaining time with friends before graduation and taking graduate student test like the Dental Admission Test (DAT) is important (Wolburg, 2016).  Drinking to cope with a stressful event decreased slightly in Senior year to 87.3% (American, 2019).

Recommended Therapy

Cognitive Behavior Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems (American, 2019).  CBT is preferred over other forms of psychotherapy, it is performed in a structed way, it generally requires fewer sessions (Mayo, 2019).  CBT, is a short-term therapy technique that can help people find new ways to behave by changing their thought patterns (Davies, 2018).  During CBT therapy the client will learn and practice techniques such as relaxation, coping, resilience, stress management and assertiveness (Mayo, 2019).  A study explored the outcome of treatment through, CBT illustrated that self-efficacy, a factor reinforced in CBT played a significant role in long-term outcome of the prevention program: Increased self-efficacy led to a successful treatment (Litt, 2018).  Improvement in awareness to young adults, CBT may be beneficial to develop coping skills around alcohol (Wolburg, 2016). The goals of CBT are to decrease the reinforcing properties of alcohol, to teach people new behaviors inconsistent with alcohol abuse, and to modify the environment to include reinforcements for activities that do not involve alcohol (Taylor, 2015).  CBT is a problem-specific, goal-oriented approach that needs the individual’s active involvement to succeed.  It focuses on their present-day challenges, thoughts, and behaviors (Davies, 2018).  Learning coping techniques for dealing with stress and relapse prevention skills enhance the prospects for long-term maintenance (Taylor, 2015).  A study concluded that CBT intervention on average had fewer days of alcohol use during the 6-month follow-up period (Deas, 2009).  Overall, the evidence shows that CBT to treat alcohol disorders are successful across a broad range of people and situations (Taylor, 2015).  Interventions with heavy-drinking college students have made use of these approaches (Taylor, 2015).

Current Study

Previous studies have not conducted research specifically like this study.  This study focuses on the treatment of CBT across the four-year college experience.  Previous studies did not focus on each specific Freshman through Senior year experience.  CBT is becoming more of a direct treatment approach to college age alcohol intervention.  Today, colleges and universities are starting to understand that success of students and alcohol use may be in self-efficacy and helping students to obtain self-control with alcohol instead of trying to eliminate it.  Students who become aware of CBT as a method to reduce alcohol consumption may not misuse alcohol while in the college environment.  With the use of CBT, self-efficacy is interwoven into therapy, which seems to increase self-awareness and decrease the amount of alcohol consumption.  Using CBT brings awareness and real life skills to help the student navigate, by their choice, situations where there will be alcohol.

References

• American Psychological Association, [APA], (2019). What Is Cognitive Behavioral Therapy?
  
  Clinical Pratice Guideline for the Treatment of Posttraumatic Stress Disorder
  
  .
• American Psychological Association, [APA], (2013), The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
• American Addiction Centers, (2019).
  
  Coping With College Stress.
  
  Brentwood
• Budny, D. D. (2004).
  
  Working With Students And Parents To Improve The Freshman Retention.
  
  Pittsburgh.
• Davies, K. (2018). How does cognitive behavioral therapy work?
  
  Medical News Today
  
  .
• Deas, D. C. (2009). Current state of treatment for alcohol and other drug use disorders in adolescents.
  
  Alcohol Research & Health
  
  .
• Litt, M. D., Kadden, R.M. & Tennen, H. (2018). Treatment Response and Non-Response in CBT and Network Support for Alcohol Disorders: Targeted Mechanisms and Common Factors.
  
  Addiction Behavior
  
  , 1407-1417.
• Lorant, V. N., Nicaise, P., Soto, V.W. & d’Hoore, W. (2013). Alcohol drinking among college students: college responsibility for personal troubles.
  
  BMC Public Health
  
  , 615.
• Mayo Clinic, (2019).
  
  Cognitive behavioral therapy.
  
  Rochester
• National Institute on Alcohol Abuse and Alcoholism, (2019) Fall Semester -A Time for Parents to Discuss the Risks of College Drinking
• Rabalais, E. (2015).
  
  10 Reasons Why Your Junior Year Of College Is The Most Stressful.
  
  Louisville: Odyssey.
• Taylor, S. E. (2015).
  
  Health Psychology.
  
  Los Angeles: McGraw-Hill Education.
• Weitzman, E. R., Nelson, T.F., & Wechsler, H. (2003). Taking up binge drinking in college: the influences of person, social group, and environment.
  
  Journal of Adolescent Health
  
  , 26-35.
• White, A., Swartzwelder, S.H. (2009). Inbound College Students Drink Heavily during the Summer before Their Freshman Year.
  
  American Journal of Health Education
  
  , 90-96.
• Wolburg, J.M. (2016). Insights for Prevention Campaigns: The power of drinking rituals in the college student experience from freshman to senior year.
  
  Journal of Current Issues & Research in Advertising
  
  , 80-94.