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Introduction to Behavioral Pediatrics

Introduction to Behavioral Pediatrics. Jodi Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute University of Nebraska Medical Center. Overview. Encopresis Enuresis An empirically-supported approach to day time toilet training

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Introduction to Behavioral Pediatrics

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  1. Introduction to Behavioral Pediatrics Jodi Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute University of Nebraska Medical Center

  2. Overview • Encopresis • Enuresis • An empirically-supported approach to day time toilet training • An empirically-supported approach to night time toilet training

  3. 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

  4. Encopresis • Medical Workup/Management • Bowel habits assessment • Education • Diet assessment/Changes • Compliance/Behavioral protocol

  5. Encopresis • Medical Workup/Management • Assessment of etiology • Slow moving bowels vs. Spina Bifida or Hirschsprung’s disease • If constipation – “clean out” • Laxatives, stool softeners, or fiber for maintenance

  6. Encopresis • Medical Workup/Management • Bowel habits assessment

  7. Encopresis • Medical Workup/Management • Education • Symptoms of constipation • Functioning of bowel • Behavioral “causes” • Diet

  8. Encopresis • Medical Workup/Management • Education • Diet assessment/Changes • Diet diary • Behavioral protocol to increase fiber • Premack principle

  9. Encopresis • Medical Workup/Management • Education • Diet assessment/Changes • Behavioral Protocol (to be discussed)

  10. 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

  11. Enuresis • Primary vs. secondary • Nocturnal vs. diurnal

  12. Enuresis • Medical evaluation • Assessment of compliance • Behavioral protocol

  13. First time toilet training • Among top concerns expressed by mothers on internet, call-in services • Most frustrating • Lots of “lore”

  14. 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 First-time toilet training

  15. Empirically supported toilet training • Thinking time question #1a: • How could you provide a child with lots of practice in toileting?

  16. 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?

  17. 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?

  18. Empirically supported toilet training • Toilet Training in a Day (Azrin & Foxx) • Repetition • Fluid load • Frequent toilet sits • Pants checks

  19. 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

  20. 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

  21. Empirically supported toilet training • Institutionalized incontinent adults • Typically developing children with toileting resistance • Mass audience of first-time learners

  22. Empirically supported toilet training • Thinking time question #2: • What if the child refuses to sit on the toilet?

  23. Encopresis • Thinking time question #3: • What would be a good behavioral protocol for a child who is soiling daily after school?

  24. Enuresis • Thinking time question #4: • What would be a good behavioral protocol for a child who is wetting daily at daycare?

  25. Empirically supported treatment for nocturnal enuresis • Assessment • Education • Urine alarm • Support to maintain integrity

  26. Empirically supported treatment for nocturnal enuresis • Assessment • Education • Prevalence • Medication vs. Urine alarm

  27. Empirically supported treatment for nocturnal enuresis • Assessment • Education • Urine alarm • Overlearning • Dry-bed training • Arousal Training • Reward for waking to moisture alarm

  28. Empirically supported treatment for nocturnal enuresis • Assessment • Education • Urine alarm • Support to maintain integrity

  29. Nocturnal enuresis • Thinking time question #5: What if the child won’t wake to the alarm?

  30. 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

  31. DarrenNumber of Wet Beds Per Week

  32. DarrenNumber of Times Mom Intervened At Night

  33. Darren: Treatment Plan • Sleep assessment: Rule out apnea • Operant training: Wake to alarm • Maintenance: Medication, no alarm

  34. Darren: Treatment Plan • Arousal Training • Familiar, loud, clock-radio. • Contingency for success. • Two alarms per night.

  35. Darren: Treatment Plan Alarms Week 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.

  36. DarrenNumber of Wet Beds Per Week

  37. DarrenNumber of Times Mom Intervened At Night

  38. DarrenFrequency of Self-Waking to Toilet

  39. DarrenNumber of Wet Beds Per Week

  40. DarrenFrequency of Self-Waking to Toilet

  41. DarrenNumber of Wet Beds Per Week

  42. 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.

  43. 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.

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