Common Childhood Problems

Common Childhood Problems Psy 4930 September 12, 2006

Common Childhood Problems • Toileting • Elimination Disorder: Enuresis and Encopresis • Eating Problems • Sleep Problems • Why do clinical child/pediatric psychologists need to know about these problems?

Toilet Training • Varies by culture • Begins earlier in other countries • 4.6 London, 7.8 months Paris, 12.4 months Stockhom • In U.S., 18-24 months is usually recommended as the starting age (24 months preferred) • Most trained btw 24-36 months (almost all by 48 mo) • Potential to ↑ parent and child stress • Pressure to train earlier - day-care centers requirements • Parent-child relationship: tantrums, refusal, punishment

Toilet Training • Unrealistic expectations • Parents and physicians disagree about the age children should stay dry for the night (2.75 yrs vs. 5.13 yrs) • If training is initiated >26 months, 2X faster than if <24 months

Toilet Training • Readiness • Bladder Control • Voluntarily control sphincter muslces • Dry for several hours • Gross motor milestones • Walking, holding objects independently • Language milestones • Receptive: 1 and 2-step commands • Expressive: communicate needs • Desire to control the impulse to urinate or defecate

Treatment Options • Retention Control Training: • Rewarding child for increasing periods of urine retention over 2 week period • Supportive approaches: • Education • Fluid restriction • Night Awakening

Case: 3-year-old is experiencing difficulty with toilet-training for bowel and bladder. Behavioral program for intensive daytime toilet training • Switch over to regular underwear. This is an important step in helping XXX get immediate unpleasant sensation when she wets herself. If necessary, you can use plastic pants over the underwear. • Have XXX sit on the toilet for 5 minutes every half hour. • If she urinates (even a little bit) or moves his/her bowels: • Give lots of praise and applause!!! • Give candy immediately (keep candy in the bathroom so it can be given quickly) • XXX is free to get off the toilet (she does not have to sit for the whole 5-minute period) • If she does not void-- after sitting 5 minutes -- say "good trying", but insist that the child stay on the toilet for the full 5 minute (no candy is given).

If she has an accident... do Positive Practice • Physically guide her to the bathroom • Give reminder in a neutral voice: "wet pants are bad“ or “oops, you’re wet” (avoid further conversation) • Guide her to pull down pants • Guide her to sit on the toilet (just sit for a couple seconds) • Guide her to stand and pull pants up • Guide her back to the area where you originally discovered the accident, and say “Now it’s time to practice so you can do it by yourself next time” and repeat steps 1- 6 three to five times. This will help to give XXX the skills to begin independent toileting. Try to make it fun. • On the last of the 3 practices, if it is close to the scheduled time that you would normally require her to have her ‘5 minute sit’, go ahead and allow her to sit for the 5 minutes. • If you are going out for an extended period and won't be able to have access to a toilet, go ahead and put on a diaper. However, it is extremely important that as soon as you come back to your home that you immediately put regular underwear back on.

Case Examples Anita Gurian, Ph.D. – NYU Child Study Center • Jackson, aged 8 , a bright, athletic, seemingly self-confident youngster, had many friends and many social invitations. Although he enjoyed attending school functions and parties, he refused invitations to sleep at a friend's house. Jackson wet his bed almost every night and tried desperately to keep it secret, but when the class went on an overnight trip, his classmates found out and teased him. "I tried to stay up all night so I wouldn't wet, but I couldn't, and then the pee soaked through my sleeping bag."

Case Examples Anita Gurian, Ph.D. – NYU Child Study Center • Rob, 6 years old, had an erratic maturational pattern. Motor and speech milestones were attained slightly after the expected ages, and he fell behind academically. Consistent with his slow development in these areas, he also had difficulty in developing urine control; he wet his bed at night and sometimes wet his clothes in school. He would usually say he was too busy or too tired to go to the bathroom. Despite Rob's teacher's attempts to handle this privately, the other children found out and called him names. Rob's parents were confused about what to do; they didn't know if he was being willful, if there was an underlying physical condition, or they were being too tough on him.

Enuresis • Enuresis: repeated involuntary or intentional discharge of urine into bed or clothes beyond the expected age for controlling urination • DSM-IV-TR age cutoff is 5 years • Enuresis must occur 2x/week for 3 consecutive months (AAFP less stringent criteria) • Or cause significant distress or impairments in functioning • Not due to General Medical Condition (GMC) or medications

Enuresis • Classifications of enuresis: • Nocturnal - only during sleep • <10% have contributory urinary tract physical abnormalities • Diurnal – only during wake hours • Greater incidence of medical problems • Mixed • Further classification: • Primary enuresis: “fixation” • Never dry historically • 80-90% of bedwetting • Secondary enuresis “regression” – at least 6 months dry

Enuresis: How common is it? • 75% have nocturnal enuresis • 60% are male • Diurnal and Mixed • 0.5 – 2% for boys/girls at age 6-7 • Uncommon after age 9 • Nocturnal • Estimated 5 - 7 million children in the U.S. • Estimated that for each year of maturity, % bedwetters  15% • 15-25% of 5-year-olds • 5% of 10-year-olds • 8% boys, 4% girls at 12-years-old • Only 1-3% adolescents

Enuresis: Other factors • More prevalent in low SES families, large families, and in families where mothers have less education • More common in boys • Possible maturational lag link • Frequent comorbidities: • Hyperactivity • Behavior problems • Anxiety • Developmental delays • Learning disabilities

Etiology of Enuresis • Biological: Organic Urinary Incontinence (1-3%) • Diabetes • Urinary tract infections • Deficiencies in nighttime antidiruetic hormone • Arginine vasopressin – delay in achieving circadian rise • Absence of learned muscle responses • Functional bladder capacity • Sleep disorder: Limited support (“deep sleepers”) • Genetic: Strong Contribution! • 77% chance of child developing enuresis -both parents • 44% chance –one parent • 15% chance –no parents

Etiology of Enuresis • Developmental status: • (AAFP)- Mentally disabled children: mental age of 4 required for diagnosis • Communication skills • Willingness to adhere to social norms • Fine and gross motor skills • Cognitive skills (e.g., planning, self-control)

Etiology of Enuresis • Psychosocial factors: • While children with emotional disturbance at ↑ risk • Most enuretic children do not have emotional or behavioral problems! • Psych Problems are typically the result, not the cause! • Still, stress, especially in 4-6-year-olds (e.g., divorce, school trauma, sexual abuse, hospitalization) • Secondary enuresis: limited support • Family disorganization or neglect

Risk Factors Enuresis • Learning disabilities • Lower intelligence • Poor school achievement • Higher rates in ADHD compared to non-ADHD

Assessment of Enuresis • Medical evaluation: • Urine analysis • Physical exam • Family history • Psychosocial factors • Child’s perception of enuresis • Treatment is more successful if child perceives problem to have psychosocial implications

Assessment of Enuresis • History of the problem: • How often and when it occurs • Type of solutions parents have tried • Environment issues • Daily fluid intake • Bedtime ritual • Proximity to bathroom

Assessment of Enuresis

Treatment:Spontaneous Remission • 15% annual rate of spontaneous remission • Between the ages of 4 and 6 years: • 71% of girls stop wetting • 44% of boys • Only 38% of children with enuresis seek medical help • Less likely if comorbid disorders are present (e.g., behavior problems)

Treatment: Daytime/Mixed Enuresis • Education • http://www.kidney.org/patients/bw/BWkidneyboy.cfm • Address any emotional/behavioral issues in therapy • Family issues • Trauma • Anxiety • Behavior problems

Treatment: Daytime/Mixed Enuresis Establish good toileting habits • Stop using diapers (exceptions) • Recording times child typically goes (every 30 minutes) • Child must show regular pattern with intervals • Regular sitting – Positive practice • 5 minutes at regular times • Make this a positive experience • Use rewards for sitting or toileting

Treatment: Daytime/Mixed Enuresis • Cleanliness training • Matter-of-fact • Cleaning themselves, clothes, floor if wet • Sitting on toilet for 5 minutes after each wet • Charting progress and providing rewards • Urine “alarm clock” • Reminder/cue • Increase awareness

Treatment: Daytime/Mixed Enuresis • Sphincter control and urine retention exercises • Not Sufficient Alone • ↑ functional bladder capacity (holding urine as long as possible during the day to stretch bladder – increase liquids during training) • Sense the “urge” • Strengthen sphincter muscle (stopping urine mid-stream technique) • Once continence established • Over-learning – increasing fluids • Fade positive reinforcement schedule • If nocturnal bedwetting: treat with urine alarm programs • Other tips: • Diet and exercise • Wait until child is ready

Nocturnal Enuresis Interventionshttp://www.kidney.org/news/newsroom/psa.cfm • Do nothing: Spontaneous Remission • Urine Alarm/Sleep Conditioning • Medication

Comparison of Treatment Modalities for Nocturnal Enuresis C. Carolyn Thiedke, M.D. American Academy of Family Physicians

Treatment:Nocturnal Enuresis • Bell-and-pad method or Urine alarm • Used frequently since 1930 • 75% success rate • Urine-sensitive pad connected to alarm • Based on classical conditioning paradigm • Child learns to associate alarm with feeling of full bladder

Urine Alarm Wet-Stop Child Bedwetting Alarm

Urine Alarm Success Rate for 12 months “Alarm systems are the most effective method for achieving nighttime dryness. A study at the Mayo Clinic comparing alarms, imipramine, and a nasal antidiuretic hormone demonstrated the clear superiority of alarm systems. A final tally of 261 children followed for one year showed the cure rate”: *Alarms used during the test included the Wet-Stop and the Sears Wee Alert Reference: J.A. Monda & D.A. Husman, Journal of Urology,Volume 154, August 1995

Treatment:Nocturnal Enuresis • Bell and pad • Average use is 6 months • Increased success through: • overlearning • Use of parental reinforcement • Continuing to use the alarm intermittently

INTENSIVE NIGHT TIME TOILET TRAINING • The bell and pad (or any other version, (e.g., Wet Stop) contains an alarm plus a moisture sensitive monitor that is placed into a little pocket that is sewn inside your child's underwear. The basic idea is to help your child learn to awaken when his/her bladder is full, so that s/he can get up and go to the bathroom at night. Once the habit is established, the bell and pad can be withdrawn. What you'll need: • Bell and pad or Wet Stops • Room in your's and your child's schedule for several sleepless nights (it might be good to start on a Friday night). Very intensive training occurs on the first and second night. • A logical and gentle rationale for your child (e.g., some kids are very heavy sleepers and need extra help in waking up to go to the bathroom at night).

First Night and Second Nights • set up the bell and pad according to instructions • before your child goes to bed, have him/her drink extra fluid • keep yourself within ear shot of the alarm • when the alarm goes off, immediately go into your child's room and with minimal attention, assist him/her in going to the bathroom to "finish up." • if your child is of an appropriate age, allow him/her to assist in the clean up (straightening out the bed, brief washing and changing pajamas). • have your child practice lying in the bed, getting up to go to the bathroom several times in a row. • encourage your child to drink more fluid before going back to sleep Third Night through 2nd week • all steps above are in place EXCEPT do not encourage additional fluids. • provide your child with rewards for each dry morning • your therapist will help you establish when to fade out the use of the bell and pad.

After 14 Consecutive Dry Nights: Overlearning • Child drinks 6-8 ounces of favorite liquid (non-caffeinated) before bedtime • Some accidents are expected • Continue until 14 more consecutive dry nights Intermittent Schedule • Tell your child that on some nights the parents will disconnect the alarm after he/she has gone to sleep • Since they will not know when it is connected, this will help him/her to learn to sleep through the night without the alarm • During the next week, disconnect alarm 2 nights, and then increase the number of nights disconnected after each completely dry week until the alarm is no longer connected If wetting occurs more than once a month for 2 months, use the alarm again until the child has 30 dry nights in a row

EncopresisDefinition and DSM Criteria • Repeated passage of feces into inappropriate places • 1x/month for 3 months • Chronological/mental age of 4 years • 2 DSM Subtypes: • With constipation and overflow incontinence (retentive: due to chronic constipation) • Without constipation and overflow incontinence (nonretentive)

Encropresis Nonretentive subgroups • Primary: failed to obtain initial bowel training • Toilet Fears: Avoidance • “Manipulative”: used by child to control the environment – ODD?? • Irritable Bowel Syndrome

Encopresis:Prevalence • Less researched than enuresis • ~ 25% of encopretic kids have enuresis • 1.5%-7.5% of children aged 6-12 • 5x more common in boys • 80-95% involve fecal constipation and retention • Associated physical symptoms: • Poor appetite • Abdominal pain • Lethargy

Encopresis:Etiology • Biological factors may play a role • Emotional factors alone do not usually account for onset of retentive • Learning factors: • Deficits in toileting skills (recognizing bodily cues, undressing, etc.) • Chronic constipation may lead to loss of previously learned toileting skills • Soiling may be reinforced by environmental factors

Encopresis:Etiology • Learning factors, continued: • Stress or anxiety may lead to loss of previously learned toileting behaviors • Developed fear of toileting due to: • Painful bowel movements • Aggressive toilet training or severe punishment for accidents • Fear of toilet • Other factors: poor diet, embarrassment, poor access, inconsistent schedules

Encopresis:Etiology • Emotional factors: • Historically, psychodynamic approaches have viewed encopresis as a sign of underlying emotional distress • Encopretic children display more behavior problems and more family problems • Nonretentive encopresis and secondary encopresis can be associated with Oppositional Defiant Disorder or Conduct Disorder

Encopresis Assessment • Medical assessment is warranted: • Impaction • Gather information about: • Stressful life events • Toilet training history • Psychological/behavioral difficulties • Typical family routine • Child and parent perceptions of problem

Encopresis:Treatment • Not as well researched as enuresis • Intervention modalities: • Education • Biofeedback • Behavioral • Medical

Encopresis:Treatment • Medical and Educational approaches: • Diet and exercise (e.g., high fiber diet, fluids) • Laxatives or enemas • Behavioral • Reinforcement, overcorrection, skill-building techniques • Biofeedback: • Muscle strengthening/relaxing exercises

Encopresis:Treatment • Schroeder & Gordon (2003) “plumbing problem” conceptualization • Education: • Information about the GI tract and it’s functioning • Information about diet and exercise • Medical Interventions: • Enema for impaction and laxatives

Encopresis:Treatment • Toileting Skills: • Sitting schedules (for 5-10 minutes 20 minutes after meals) • Reinforcement for sitting and using the toilet • “Clean pants check” • Reward if clean • Child helps clean up if dirty

Why is Sleep Important for you to know about? • Children with depression, anxiety, behavior problems, and ADHD have ↑ risk for sleep problems • Sleep disturbance (e.g., sleep-disordered breathing, sleep restriction, fragmented sleep) is associated with worse neuropsychological (attention, executive functioning, motor skills, reaction time performance), behavioral (increased hyperactivity, inattention, impulsivity, conduct problems), and emotional (anxious/depressive symptoms, withdrawal, somatic complaints) functioning (Archbold et al., 2004; O’Brian et al., 2004; Fallone et al., 2000; Owens et al., 2000; Owens, 2005) • 37% of children kindergarten -4th grade suffer from at least 1 sleep-related problem (www.sleepfoundation.org)

Sleep Disturbances in Children • Young children with sleep problems tended to have problems 3 years later • Of 8-year-olds with sleep wakening problems, 40% had sleep problems at age 3 • Evidence suggests that sleep problems do not “go away”

Basics of Sleep - Stages • REM - Dreaming, brains “active”, body immobile • NREM - “quiet”, deep “restorative” stages associated with tissue growth/repair, hormones released for development

Basics of Sleep – REM • Younger children have somewhat different patterns of sleep than adults, but typically develop a normal adult cycle by 8 years • http://www.sleepfoundation.org/doze/

Common Childhood Problems