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

2. 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

3. Teaching Behavioral Skills The Three Essentials: 1. Predictability In your daily structure In the consequences you provide

4. 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

5. 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 3. “Big Difference”

6. 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.

7. Prerequisite to toileting, sleeping, and eating Being a good listener

8. Increasing Compliance 1. Frequent, intermittent “bursts” of attention for average and okay behavior 2. Build relationship by using Child’s Game 3. Compliance Training

9. Teaching Behavioral Skills The Child’s Game: A relationship-building activity that makes children want to earn your POSITIVE attention.

10. Teaching Behavioral Skills DO Describe Praise Touch DON’T Command Reprimand Question

11. Compliance Training Effective Commands: Simple Direct One at a time Start small

12. 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.

13. 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.

14. 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

15. 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

16. Addressing Toileting Problems

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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.

23. Scenario 2: You need to help with the toilet training process In general, follow the rules of: Consistency Repetition High Contrast

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Treatment of retentive encopresis Education and demystification Education and demystification Clean out the system (e.g., enemas and/or laxatives) Scheduled toilet sits Scheduled toilet sits Reward toilet sits, BMs after scheduled sits, and self-initiated BMs Reward toilet sits, BMs after scheduled sits, and self-initiated BMs Increase fiber, fluids,activity level Increase fiber, fluids, activity level Possibly use stool softener Ensure child’s feet are on flat surface when toileting Ensure child’s feet are on flat surface when toileting

31. Treatment of encopresis (continued) Data collection Data collection When do they go? Do they go frequent enough? Is treatment effective? Can we decrease meds?

32. Solving Sleep Problems

33. Common Sleep Problems DSM-IV Types Insomnia/Hypersomnia Nightmare Disorder Sleep Terror Disorder Sleepwalking Disorder

34. Sleep Problems Most common: Bedtime resistance Morning wake-up problems Sleep-onset delays up to 1 hour Night awakening

35. Sleep Problems Most common: Bedtime resistance Sleeping independently is a skill Laying in bed is “time-out”

36. Sleep Problems What could increase consistency? What could provide repetition? How could high contrast be used?

37. 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.

38. 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

39. 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

40. 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

41. Grab Bags: Creating Effect Write down list of “reinforcers” on index card Place in box/bag Meets specified goal = reward card

42. “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

43. “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

44. 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

45. 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

46. Solving Meal Problems

47. Types of feeding disorders Content of food Quantity of food Method of eating Most likely to see food refusal: “The Picky Eater”

48. Mealtime Behavior Problems: How to solve “The Picky Eater” Problem What could increase consistency? What could provide repetition? How could high contrast be used?