Toileting, Sleeping, and Eating: Three Daily Common Problems Rachel J. Valleley, Ph.D. & John Begeny, M.S. Munroe-Meyer Institute University of Nebraska.

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?