Introduction to Behavioral PediatricsJodi Polaha, Ph.D.Assistant Professor, PediatricsMunroe-Meyer InstituteUniversity of Nebraska Medical Center
Overview
Encopresis Enuresis An empirically-supported
approach to day time toilet training
An empirically-supported approach to night time toilet training
Encopresis
Repeated passage of feces into inappropriate places whether involuntary or intentional
At least one such event a month for 3 months
At least 4 years old Not due to direct effects of substance or
medical condition except constipation With constipation and overflow incontinence Without constipation and overflow
incontinence
Encopresis
Medical Workup/Management Bowel habits assessment Education Diet assessment/Changes Compliance/Behavioral protocol
Encopresis
Medical Workup/ManagementAssessment of etiology
• Slow moving bowels vs. Spina Bifida or Hirschsprung’s disease
If constipation – “clean out”Laxatives, stool softeners, or fiber
for maintenance
Encopresis
Medical Workup/Management Bowel habits assessment
Encopresis
Medical Workup/Management Education
Symptoms of constipationFunctioning of bowel Behavioral “causes”Diet
Encopresis
Medical Workup/Management Education Diet assessment/Changes
Diet diaryBehavioral protocol to increase
fiber• Premack principle
Encopresis
Medical Workup/Management Education Diet assessment/Changes Behavioral Protocol (to be
discussed)
Enuresis
Repeated voiding of urine into bed or clothes (whether involuntary or intentional)
Behavior is clinically significant (at least 2x/wk for 3 mos or causes impairment)
At least 5 years old (developmentally) Not due to substance/medical
condition
Enuresis
Primary vs. secondary Nocturnal vs. diurnal
Enuresis
Medical evaluation Assessment of compliance Behavioral protocol
First time toilet training
Among top concerns expressed by mothers on internet, call-in services
Most frustrating Lots of “lore”
First-time toilet training
Passive “child-oriented”
Brazelton, 1962 Physical
maturity, interest, and “psychological readiness”
“relax, be patient”
Intensive “toilet-training
in a day” Azrin & Foxx, 1974
Physiological readiness and compliance
Principles of operant conditioning
Empirically supported toilet training Thinking time question #1a:
How could you provide a child with lots of practice in toileting?
Empirically supported toilet training Thinking time question #1a, b:
How could you provide a child with lots of practice in toileting?
How could you provide predictabilty in structuring programming?
Empirically supported toilet training Thinking time question #1a, b, c:
How could you provide a child with lots of practice in toileting?
How could you provide predictabilty in structuring programming?
How could you provide a high contrast to help skill acquisition?
Empirically supported toilet training Toilet Training in a Day (Azrin &
Foxx)Repetition
• Fluid load• Frequent toilet sits• Pants checks
Empirically supported toilet training Toilet Training in a Day (Azrin &
Foxx)Repetition
• Fluid load• Frequent toilet sits• Pants checks
High Contrast• Rewards for compliance with sits,
successful voiding in toilet, and dry pants
• Clean-up and overcorrection for wetting
Empirically supported toilet training Toilet Training in a Day (Azrin & Foxx)
Repetition• Fluid load• Frequent toilet sits• Pants checks
High Contrast• Rewards for compliance with sits, successful
voiding in toilet, and dry pants• Clean-up and overcorrection for wetting
Predictability• Consistent schedule for toilet sits/pants checks• Star chart with grab bag• Use of attention
Empirically supported toilet training Institutionalized incontinent
adults Typically developing children
with toileting resistance Mass audience of first-time
learners
Empirically supported toilet training Thinking time question #2:
What if the child refuses to sit on the toilet?
Encopresis
Thinking time question #3:What would be a good behavioral
protocol for a child who is soiling daily after school?
Enuresis
Thinking time question #4:What would be a good behavioral
protocol for a child who is wetting daily at daycare?
Empirically supported treatment for nocturnal enuresis Assessment Education Urine alarm Support to maintain integrity
Empirically supported treatment for nocturnal enuresis Assessment Education
PrevalenceMedication vs. Urine alarm
Empirically supported treatment for nocturnal enuresis Assessment Education Urine alarm
OverlearningDry-bed trainingArousal Training
• Reward for waking to moisture alarm
Empirically supported treatment for nocturnal enuresis Assessment Education Urine alarm Support to maintain integrity
Nocturnal enuresis
Thinking time question #5: What if the child won’t wake to the alarm?
Nocturnal enuresis: Trouble shooting “Darren” 13 year-old Caucasian male No medical, psychiatric,
academic history or concerns Life-long history of bedwetting Two, one-year trials with
moisture alarm. Currently treated with DDAVP
DarrenNumber of Wet Beds Per Week
0
2
4
6
8
10
12
14
16A
pril
Apr
il
Apr
il
Apr
il
May
May
May
May
June
June
June
June
Wet Beds PreTreatmentWet Beds 1 DDAVP
Wet Beds 2 DDAVP
DarrenNumber of Times Mom Intervened At Night
0
2
4
6
8
10
12
14
16A
pril
Apr
il
Apr
il
Apr
il
May
May
May
May
June
June
June
June
Mom Pre TreatmentMom with 1 DDAVPMom with 2 DDAVP
Darren: Treatment Plan
Sleep assessment: Rule out apnea
Operant training: Wake to alarm Maintenance: Medication, no
alarm
Darren: Treatment Plan
Arousal TrainingFamiliar, loud, clock-radio.Contingency for success.Two alarms per night.
Darren: Treatment Plan
AlarmsWeek 1: 5:00 a.m. and 7:00 a.m.Week 2: 5:15 a.m. and 6:45 a.m.Week 3: 5:30 a.m. and 6:30 a.m.Week 4: 6:00 a.m.Week 5: 6:00 a.m.Week 6: 6:30 a.m.
DarrenNumber of Wet Beds Per Week
0
2
4
6
8
10
12
14
16
Pre Treatment1 DDAVP2 DDAVP2 DDAVP + Alarm
DarrenNumber of Times Mom Intervened At Night
0
2
4
6
8
10
12
14
16
Pre Treatment1 DDAVP2 DDAVP2 DDAVP + Alarm
DarrenFrequency of Self-Waking to Toilet
0
2
4
6
8
10
12
14
16
Pre Treatment1 DDAVP2 DDAVP2 DDAVP and Alarm
DarrenNumber of Wet Beds Per Week
02468
10121416
Pre Treatment1 DDAVP2 DDAVP2 DDAVP + Alarm2 DDAVP
DarrenFrequency of Self-Waking to Toilet
02468
10121416
Pre Treatment1 DDAVP2 DDAVP2 DDAVP and Alarm2 DDAVP
DarrenNumber of Wet Beds Per Week
02468
10121416
Pre Treatment1 DDAVP2 DDAVP2 DDAVP + Alarm2 DDAVP1 DDAP + Alarm
Darren: Conclusions
Practice with waking to scheduled alarms:improved independence.increased frequency of self-waking
to toilet.increased frequency of sleeping
through night dry.supplemented medication therapy.
Trouble Shooting Arousal Problems
Evaluation for sleep disorder, particularly apnea.
Programmed alarms for “easy” times and phase to time when urinating likely.
Programmed alarms for times when urinating likely and phase toward morning.
Supplement behavioral intervention with medication.
Use of familiar “alarm clock” gives volume control/replaces moisture alarm.