Toileting, Sleeping, and Eating: Three Daily Common Problems Rachel J. Valleley, Ph.D. & John Begeny, M.S. Munroe-Meyer Institute University of Nebraska.
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Toileting, Sleeping, and Eating: Three Daily Common Problems
Rachel J. Valleley, Ph.D. & John Begeny, M.S.
Munroe-Meyer InstituteUniversity of Nebraska Medical
Center
What does toileting, sleeping, and eating have in common?
Happen every day Things kids don’t like to do If not good at listening, often have
problems in one or more of these areas
Teaching Behavioral Skills
The Three Essentials:1. Predictability
In your daily structure In the consequences you provide
Teaching Behavioral Skills
The Three Essentials:1. Predictability
In your daily structure In the consequences you provide
2. Practice Break the new skill down to make it easy at first Give lots of opportunities to try it (over and
over) Provide predictable feedback for success vs.
failure
Teaching Behavioral SkillsThe Three Essentials:1. Predictability
In your daily structure In the consequences you provide
2. Practice Break the new skill down to make it easy at
first Give lots of opportunities to try it (over and
over) Provide predictable feedback for success vs.
failure3. “Big Difference”
Teaching Behavioral Skills
Creating a “Big Difference”
Your consequence for demonstrating a skill appropriately should be
VERY DIFFERENT than your consequence for
demonstrating a problem behavior.
Prerequisite to toileting, sleeping, and eating
Being a good listener
Increasing Compliance
1. Frequent, intermittent “bursts” of attention for average and okay behavior
2. Build relationship by using Child’s Game
3. Compliance Training
Teaching Behavioral Skills
The Child’s Game:A relationship-building activity that
makes children want to earn your POSITIVE attention.
Teaching Behavioral Skills
DO Describe Praise Touch
DON’T Command Reprimand Question
Compliance Training
Effective Commands:
Simple Direct One at a time Start small
Compliance Training
Give simple, practice command Wait 5-10 seconds. If follows,
praise/Big Effect. If not, give time out warning if does not comply. Wait 5-10 seconds. If follows, praise/Big Effect. If not, put in time out. After time out, repeat command and procedure until command is followed.
Time out
What is time out?
Time out is the removal of attention, tangibles, or anything interesting to the child for a brief amount of time.
Misconceptions & mistakes:Time out
Not the chair Have to sit quietly before time starts 1 minute per year Think about what did wrong and feel
sorry Talking to child in time out Not expecting extinction burst
Decreasing the “No” How to do Time Out:
Stop talking once told “Time Out” Get to chair/spot with minimal guidance Do not attend to anything in time out Stay close enough to monitor but be aloof Child serves 2-3 minutes Let child out Follow up with expecting appropriate
behavior
Addressing Toileting Problems
Readiness for toilet training Age: at least 20 months, preferably 2
years or older Most kids are ready by age 3, though
accidents commonly occur through age 5
Physical readiness Pick up toilet seat; lower/raise pants;
walk from room to room easily Bladder readiness
staying dry several hours at a time; urinating 4-6 times/day and fully emptying
Readiness continued Language
understands words like “wet,” “dry,” “pants,” and “bathroom.”
Instructional Understands simple directions Compliant with directions
Bladder and Bowel Awareness Look for signs, not just words (e.g.,
the pee-pee dance)
Preliminary suggestions
Let your child watch and explain in simple words what you’re doing
Teach child to raise/lower pants Make sure child can follow
instructions Set out a potty chair Give a lot of praise for any type of
toileting behavior
Scenario 1: Toileting needs to happen NOW
Steps for toilet training Increase fluid intake (1 cup of liquid/hour) Frequent toilet sits (approximately 1
every 15-30 minutes). Check for dry pants every 15-30 min. and
praise/reward for dryness (e.g., dot-to-dot)
Also reward for using toilet Use positive practice procedures
Practice going to toilet 10 times after each accident
Rewarding Desired Behavior
The effects of our actions determine whether we will repeat them
Reward: toilet sits (and other toileting behaviors), dry pants, using toilet
Use: praise incentives and/or other mediums: sticker charts,
Magic Circle charts, dot-to-dot charts
Other important points about positive practice
Remain calm and accept that accidents will occur
When finding wet pants, say in matter of fact tone that the child must practice now
Before practicing, say that he/she will have to put on dry pants. Otherwise, avoid talking.
Start at scene of accident then calmly take child by hand and lead to bathroom. Then have child lower pants, sit on toilet, get up, and pull up pants. Return to same spot and repeat 9 times.
As always, praise for actually using toilet.
Scenario 2: You need to help with the toilet training process
In general, follow the rules of: Consistency Repetition High Contrast
Consistency: Formal consequences reliably occur
for a) dry or soiled pants, b) BMs or urinating in toilet
Repetition: High fluid load Pants checks with immediate
feedback Schedules toilet sits
High Contrast: Grab bag and/or enthusiastic praise
for successful sits, being dry, and voids in toilet
Clean up and positive practice for accidents
Little attention for accidents
Scenario 3: Child with an elimination disorder Types of disorders:
1. Enuresis• Diurnal• Nocturnal• Both
2. Encopresis• With constipation• Without constipation
• Note: NOT thought to be caused by sexual abuse
Diurnal Enuresis
What is it?Individuals of at least 5 years of age
who urinate in clothing two times per week for at least 3 months, or presence of clinically significant distress or impairment in social, academic, or other important areas of functioning
Diurnal Enuresis
Prevalence: approximately 0.5% to 2% of 6 and 7-year-old girls and boys Much less common than nocturnal enuresis
Comprehensive assessment is important
General treatment approaches Medically based Treat noncompliance?? Increase awareness of full bladder Reinforcement program
Encopresis with constipation
Individuals who are at least 4 years old who pass feces into inappropriate places (e.g., clothing, floor) at least once per month for at least 3 months
Can be voluntary or involuntary, but is not due to medications or other substances Over 90% is involuntary and due to
constipation
Encopresis facts
Approximately 1 to 5% of pediatric patients
Primary cause is fecal retention, which in the large majority of cases is beyond the child’s immediate control
Treatment of retentive encopresis Education and demystificationEducation and demystification Clean out the system (e.g., enemas and/or
laxatives) Scheduled toilet sitsScheduled toilet sits Reward toilet sits, BMs after Reward toilet sits, BMs after
scheduled sits, and self-initiated BMsscheduled sits, and self-initiated BMs Increase fiber, fluids,Increase fiber, fluids, activity levelactivity level Possibly use stool softener Ensure child’s feet are on flat surface Ensure child’s feet are on flat surface
when toiletingwhen toileting
Treatment of encopresis (continued)
Data collectionData collection When do they go? Do they go frequent enough? Is treatment effective? Can we decrease meds?
Solving Sleep Problems
Common Sleep Problems
DSM-IV Types Insomnia/Hypersomnia Nightmare Disorder Sleep Terror Disorder Sleepwalking Disorder
Sleep Problems
Most common: Bedtime resistance Morning wake-up problems Sleep-onset delays up to 1 hour Night awakening
Sleep Problems
Most common: Bedtime resistance Sleeping independently is a skill Laying in bed is “time-out”
Sleep Problems
What could increase consistency? What could provide repetition? How could high contrast be used?
Sleep Problems Bedtime resistance
1. Assess overall noncompliance.2. Take data.3. Address consistency of pre-bed routine.4. Move bedtime closer to sleep onset.5. Set “sleep window.” 6. Use some ignoring procedure.7. Use some sort of reinforcement for sleep.8. Extend sleep window.
Naps: Steps to good sleep Demonstrate sleep compatible behavior Prompt sleep compatible behavior Praise sleep compatible behavior
FREQUENTLY at first Use stickers for sleep compatible
behavior Offer incentive to follow nap if quiet
during naptime Use a time out if absolutely necessary
Common Objections to Using Tangible Rewards
Rewarding children for good behavior is bribery
Shouldn’t reward children for what they should already do
Expect rewards for everything
Preference Assessments
Before developing any incentive program, determine what the child likes by Watching what they chose when
many options available or over time Pair objects together and ask which
they prefer Have child make a list of reinforcers
Grab Bags: Creating Effect
Write down list of “reinforcers” on index card
Place in box/bag Meets specified goal = reward card
“Reinforcer” Menus: Option 1
Set criteria for each level of behavior
Select “reinforcers” for each level
“Reinforcers” should be of more value to child with each level
Okay (1-3)
Sticker, Sucker, Read book
Good (4-6)
Pencils, Rent video, Go to DQ
Great (7+)
Go to movie, Have friend over, Stay up late
“Reinforcer” Menus: Option 2 Each day give 3-5 options from big list
of “reinforcers” that the child can pick from and earn that day if criteria met
Rewards Available Today
Go to Park, 30 minutes computer, Play Monopoly
Dot-to-dots
As child engages in sleep compatible behavior, they earn a line on chart and is praised as behavior occurs
When completed dot-to-dot, earns reward
Would want to initially have earn lines after few seconds of sleep compatible behavior and slowly increase time between bursts of attention
Magic Circle Charts
Each time child is quiet during nap, earns a star/sticker on chart and is praised as behavior occurs
When lands on “magic circle”, child earns incentive
Best to use after dot-to-dot and child is more consistently quiet during nap
Solving Meal Problems
Types of feeding disorders
Content of food Quantity of food Method of eating
Most likely to see food refusal: “The Picky Eater”
Mealtime Behavior Problems: How to solve “The Picky Eater” Problem What could increase consistency? What could provide repetition? How could high contrast be used?
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