1、Early Childhood Behaviour Problems (continued)Child Assessment & Therapy: 512-924October 2007Gaining control of bladder & bowelNormal developmentInfants: urinate often, small amounts, reflex1-2 years: child notices full bladder, void less often, larger amountsAge 3: child holds for longer periods, c

2、an get to toiletPreschooler often cannot empty bladder unless it is full (eg cant go before a car trip on request)20 24 months a good age to begin in normally developing child. Older age, easier to learnSigns of readiness:Being able to sit on potty or toilet seat (coordination)Able to understand sim

3、ple instructions, cooperativeAble to hold urine for 1-2 hours without leakageRegular bowel movements, no soiling during sleepSummer easier in cold climatesAvoid times of stress (eg birth of sibling)Toilet trainingEvery Parent (Sanders): active teaching, using doll as modelToilet training, Bedwetting

4、 and Soiling (Herbert, PACTS series): more gradualManaging Problem Behaviours (Dodd)Ways of toilet trainingAll approaches emphasize importance of:No undue pressure, calm, matter of fact approachMinimal attention and no negativity about mistakesPositive attention for success (praise, maybe stickers)(

5、Remember age of child: tends to be oppositional!)Principles of toilet trainingUseful suggestionsIncrease fluid to increase rate of learningOnce not in nappy at home, remove nappy altogetherPlastic sheet covered with towel for car seatTake potty everywhere initiallyKeep child in uncarpeted areas Boys

6、 to sit down initially, learn to stand laterIntellectual, physical disabilities:Similar issues of readiness (likely to be older)More specific training, based on careful observation and monitoring of childs current routine of eating/drinking; elimination, routines; behaviours prior to eliminationRole

7、 of occupational therapists where physical difficultiesToilet training children with disabilitiesAutism Spectrum Disorder issues of:CommunicationSensory issuesPreference for routine, difficulty adjusting to new behavioursMotor planning difficultiesDifficulty imitatingSequential learning: (identify h

8、ow the child learns best)Anxiety levelsToilet training children with disabilitiesNocturnal enuresis: bedwetting in a child over 5 years (or equiv. developmentally)Diurnal enuresis:wetting during the day in children 5 years and overPrimary enuresis:where a child has never been dry longer than 6/12 mo

9、nthsSecondary enuresis: children who have been dry longer than 6/12 months & begin wetting againEnuresis: terminology% bed-wetting at different ages(variable figures depending on definition of bed-wetting) Age in years345678914% who wet the bed2015 12 (15-20)12 8 (7)65 4 (15 yr 1-2%)More boys wet be

10、ds than girlsSeek help at ages 5 7 yearsOften a family history of bed-wetting: geneticDevelopmental delayEmotional stresses may lead to secondary enuresis (but rarely severe emotional problems)Medical reasons occasionally (eg urinary tract infection, epileptic seizures, central nervous system or bla

11、dder) Causes of enuresisHigh production of urine at night, associated with insufficient arginine vasopressin (avp) release at night(Wetting soon after going to bed, large wet patches)Small functional bladder capacity (fbc) associated with bladder overactivity. (Nighttime: multiple bedtime wettings,

12、small wet patches)Possibly a difficulty with arousal from sleep when bladder reaches its maximum capacity(Butler & Holland 2000)Causes of enuresis (continued):The Three-Systems ModelEducational, simple strategiesRefer to specialist or clinicRole of PsychologistNeed medical review to exclude bladder

13、infections, constipation, renal problems Monitor nighttime wetting (frequency, timing, amount, etc)Measure functional bladder capacity if seems indicatedAssessment (and clinical interview)Encouragement and reinforcementKeep a record of wet and dry bedsReward (small and as soon as possible after the

14、dry bed)Not suitable for a child who invariably wets: too difficult and demoralisingToilet routine: practice getting out of bed and going to toilet a number of times, make sure easy accessLifting, fluid restriction before bedtime: not effectiveCaffeineSome studies suggest eliminating caffeine from d

15、iet helpfulForms of treatmentBladder stretching exercises (if child is passing urine often and in small amounts)Control training: helps children gain more control over their muscles by stop and start flow of urine when using toiletForms of treatment (where bladder overactivity, frequency of urinatio

16、n)Scheduled waking if wets at same time each nightBell and Pad (bedwetting alarm; pad & buzzer)Cochrane review of 52 trials:About 2/3 became dry during alarm use50% remained dry after treatmentRelapse rates reduced when over-learning (giving extra fluids at bedtime once successfully dry) occurredMor

17、e effective than medicationsNB Higher rates of success reported in other studies. More children successful if have second trial.Forms of treatment (where lack of avp release & difficulty arousing with full bladder)Desmopressin (also called Minirin) is a synthetic hormone which concentrates the urine

18、. Safe and free of side effects. Used at RCH for children who do not become dry with the alarm.Anticholinergics for bladder overactivityTricyclics such as Imipramine, poor efficacy, side effectsDrug treatment on its own is rarely an effective long-term treatment, high rates of relapseForms of treatm

19、ent (Medication)Complex behavioural interventions(eg Dry Bed Training: DRT, Azrin, 1973):Developed for adults with intellectual disabilitiesDemanding procedureAlarm seems to be the effective componentNowadays eliminate reprimands and positive practice elementsForms of treatment (continued)Different

20、aetiology to nocturnal enuresis:Organic causes: structural abnormalities and functional disorders of the urinary tractDaytime EnuresisAn inability to control the bowel fully, resulting in soiling:Primary faecal incontinenceSecondary: have gained control and lose itBehavioural/emotional issues (not e

21、ncopresis): play with or smear faeces; choose to soil in pants.Encopresis“Learning to go to the toilet is not a particularly difficult task, and in our culture is usually accomplished about age two. The failure of children age four and above to exhibit this skill elicits intense emotions both in par

22、ents and professionals. The distress of the child and family are all too apparent.” (Baglow, 1987)Can be a battleground: need to form a team.EncopresisIn most cases, a result of prolonged constipation leading to stretched muscles in the bowel which cannot send messages reliably to the brain and cann

23、ot contract reliably (retention & overflow)Anal fissure, and other reasons leading to pain associated with defecationIntellectual or physical disabilitiesSocial: neglectful or coercive toiletingPrimary CausesFrequency, type and timing of soilingMemories of painful experiences trying to defecateDevel

24、opmental level of child, medical issuesToilet training, in particular bowel training methods and timingAssessmentParent-child relationship, separation issuesQuality of marital relationshipPersonality of parents, psychological state of parent (eg depression), parents own childhood experiencesStressor

25、s Careful analysis of all factors choice of treatmentAssessment (continued)Medical/dietary treatmentMay need enema if constipated with a mass of faecesOn-going treatment of constipation motivation of childdaily routine (sit on toilet 5-10 minutes 20 minutes after breakfast, perhaps after other meals

26、)fibre & fluid in dietexerciseon-going laxatives for a whileTreatmentBehavioural (where original factors leading to encopresis have vanished)Star chart, reward schemeSneaky Poo (White, 1984; Heins & Ritchie, 1985, 1988): externalising of the problem, forming a team to fight it, using planning and pr

27、actice to prepare, and increasing motivation partially through telling othersTreatment (continued)Parent Counselling:Education about digestion and defecation.Management of practical matters (diet, regular toileting programme)Hear the parents emotional responses (often anger) relating to the soiling.

28、 Discouragement of punitive response.Treatment (continued)Family Therapy: enmeshment, overprotectiveness, rigidity, lack of conflict resolution: general family organisation and functioningPsychotherapy for the child: where simple behavioural approaches not possible, nor family therapyOther TherapyCa

29、se StudyMajor theoriesSocial learningAttachment TheoryFamily systems theory (especially structural)Cognitive / attributional theory Ecological ModelFeeding difficultiesInterplay of biological, organic, emotional, relationship and social learning factorsFactorsInability to read childs cues of hunger

30、and satietyBeliefs about appropriate eating (eg ethnicity)Lack of provision of pleasant eating environment: chaotic/disorganised (TV, toys)Inability to model appropriate eatingInability to shape learning independent feedingOver-concern with feeding challenges of toddlerhoodFactors: social env, paren

31、tingIrritabilityLack of responsivenessSensory issuesOppositional behaviourFactors: child characteristicsCleft palateRefluxSwallowing difficultiesCystic fibrosisInvolvement of Speech Pathologist if oro-motor factors involved in swallowing.Factors: organic, biological25-35% of pre-schoolers have feedi

32、ng problems:Selective eating of types of foodLittle eating, picking through the dayRefusal to eat new foods (neophobia)Types of Feeding ProblemsDelay in learning to feed selfPace of feeding: too slow or gorgingDisruptive at tableRumination, vomitingFood refusal, failure to thrive (below 3rd percenti

33、le for body weight)Types of Feeding ProblemsMany causes:Organic (inadequate nutrition, malabsorption, chronic infection, major structural congenital abnormalities, metabolic and endocrine defects)Non-organic, associated with some deficit in nurturance and physical intimacy(see Iwaniec, 1995, re trea

34、tment)Failure to ThrivePattern of eating and associated behaviour (Food diary)Height and weight informationMedical/developmental factorsHistory of pain associated with eatingInteraction with parent, especially around eatingFamily factorsEmotional factors (anxiety, depression)AssessmentResearch indic

35、ates that it takes a good deal to interrupt a childs natural tendency to accept and regulate food intake. Meal by meal intake can vary, but energy intake tends to remain fairly constant.Therefore:Provision of appropriate food is parents roleLeave the child to manage their intakeSocial context of mea

36、ls:Family mealtimes, routine and consistency Positive env: praise/attention for appropriate behLimits placed on inappropriate beh: ignored, natural consequence (removal of food), time outModelling of enjoyable eating by parentsNot too many distractions (TV, phone, etc)Early steps to establishing mealtimes as pleasantMatching amount of food to