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.