Transcript Common Childhood Problems: Enuresis and Encopresis

Common Childhood Problems
Psy 4930
September 12, 2006
Common Childhood Problems
• Toileting
– Elimination Disorder: Enuresis and
Encopresis
• Eating Problems
• Sleep Problems
• Why do clinical child/pediatric
psychologists need to know about these
problems?
Toilet Training
• Varies by culture
– Begins earlier in other countries
– 4.6 London, 7.8 months Paris, 12.4 months Stockhom
• In U.S., 18-24 months is usually recommended
as the starting age (24 months preferred)
• Most trained btw 24-36 months (almost all by 48
mo)
• Potential to ↑ parent and child stress
– Pressure to train earlier - day-care centers
requirements
– Parent-child relationship: tantrums, refusal,
punishment
Toilet Training
• Unrealistic expectations
– Parents and physicians disagree about the
age children should stay dry for the night
(2.75 yrs vs. 5.13 yrs)
• If training is initiated >26 months, 2X
faster than if <24 months
Toilet Training
•
Readiness
1. Bladder Control
–
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Voluntarily control sphincter muslces
Dry for several hours
2. Gross motor milestones
–
Walking, holding objects independently
3. Language milestones
–
–
Receptive: 1 and 2-step commands
Expressive: communicate needs
4. Desire to control the impulse to urinate or
defecate
Treatment Options
• Retention Control Training:
– Rewarding child for increasing periods of
urine retention over 2 week period
• Supportive approaches:
– Education
– Fluid restriction
– Night Awakening
Case: 3-year-old is experiencing difficulty with toilettraining for bowel and bladder.
Behavioral program for intensive daytime toilet training
A. Switch over to regular underwear. This is an important step in
helping XXX get immediate unpleasant sensation when she wets
herself. If necessary, you can use plastic pants over the underwear.
B. Have XXX sit on the toilet for 5 minutes every half hour.
 If she urinates (even a little bit) or moves his/her bowels:
1) Give lots of praise and applause!!!
2) Give candy immediately (keep candy in the bathroom so it can
be given quickly)
3) XXX is free to get off the toilet (she does not have to sit for the
whole 5-minute period)
 If she does not void-- after sitting 5 minutes -- say "good trying",
but insist that the child stay on the toilet for the full 5 minute (no
candy is given).
C.
•
D.
If she has an accident... do Positive Practice
1) Physically guide her to the bathroom
2) Give reminder in a neutral voice: "wet pants are bad“ or
“oops, you’re wet” (avoid further conversation)
3) Guide her to pull down pants
4) Guide her to sit on the toilet (just sit for a couple seconds)
5) Guide her to stand and pull pants up
6) Guide her back to the area where you originally
discovered the accident, and say
“Now it’s time to practice so you can do it by yourself next
time” and repeat steps 1- 6 three to five times. This will
help to give XXX the skills to begin independent toileting.
Try to make it fun.
On the last of the 3 practices, if it is close to the scheduled
time that you would normally require her to have her ‘5 minute
sit’, go ahead and allow her to sit for the 5 minutes.
If you are going out for an extended period and won't be able
to have access to a toilet, go ahead and put on a diaper.
However, it is extremely important that as soon as you come
back to your home that you immediately put regular
underwear back on.
Case Examples
Anita Gurian, Ph.D. – NYU Child Study Center
• Jackson, aged 8 , a bright, athletic,
seemingly self-confident youngster, had many
friends and many social invitations. Although
he enjoyed attending school functions and
parties, he refused invitations to sleep at a
friend's house. Jackson wet his bed almost
every night and tried desperately to keep it
secret, but when the class went on an
overnight trip, his classmates found out and
teased him. "I tried to stay up all night so I
wouldn't wet, but I couldn't, and then the pee
soaked through my sleeping bag."
Case Examples
Anita Gurian, Ph.D. – NYU Child Study Center
• Rob, 6 years old, had an erratic maturational pattern.
Motor and speech milestones were attained slightly
after the expected ages, and he fell behind
academically. Consistent with his slow development in
these areas, he also had difficulty in developing urine
control; he wet his bed at night and sometimes wet his
clothes in school. He would usually say he was too
busy or too tired to go to the bathroom. Despite Rob's
teacher's attempts to handle this privately, the other
children found out and called him names. Rob's parents
were confused about what to do; they didn't know if he
was being willful, if there was an underlying physical
condition, or they were being too tough on him.
Enuresis
• Enuresis: repeated involuntary or intentional
discharge of urine into bed or clothes beyond the
expected age for controlling urination
• DSM-IV-TR age cutoff is 5 years
• Enuresis must occur 2x/week for 3 consecutive
months (AAFP less stringent criteria)
• Or cause significant distress or impairments in
functioning
• Not due to General Medical Condition (GMC) or
medications
Enuresis
• Classifications of enuresis:
– Nocturnal - only during sleep
• <10% have contributory urinary tract physical abnormalities
– Diurnal – only during wake hours
• Greater incidence of medical problems
– Mixed
• Further classification:
– Primary enuresis: “fixation”
• Never dry historically
• 80-90% of bedwetting
– Secondary enuresis “regression” – at least 6 months
dry
Enuresis: How common is it?
• 75% have nocturnal enuresis
• 60% are male
• Diurnal and Mixed
– 0.5 – 2% for boys/girls at age 6-7
– Uncommon after age 9
• Nocturnal
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Estimated 5 - 7 million children in the U.S.
Estimated that for each year of maturity, % bedwetters  15%
15-25% of 5-year-olds
5% of 10-year-olds
8% boys, 4% girls at 12-years-old
Only 1-3% adolescents
Enuresis: Other factors
• More prevalent in low SES families, large
families, and in families where mothers have
less education
• More common in boys
– Possible maturational lag link
• Frequent comorbidities:
–
–
–
–
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Hyperactivity
Behavior problems
Anxiety
Developmental delays
Learning disabilities
Etiology of Enuresis
• Biological: Organic Urinary Incontinence (13%)
– Diabetes
– Urinary tract infections
– Deficiencies in nighttime antidiruetic hormone
• Arginine vasopressin – delay in achieving circadian rise
– Absence of learned muscle responses
– Functional bladder capacity
– Sleep disorder: Limited support (“deep sleepers”)
• Genetic: Strong Contribution!
– 77% chance of child developing enuresis -both
parents
– 44% chance –one parent
– 15% chance –no parents
Etiology of Enuresis
• Developmental status:
• (AAFP)- Mentally disabled children: mental
age of 4 required for diagnosis
– Communication skills
– Willingness to adhere to social norms
– Fine and gross motor skills
– Cognitive skills (e.g., planning, selfcontrol)
Etiology of Enuresis
• Psychosocial factors:
– While children with emotional disturbance at ↑ risk
– Most enuretic children do not have emotional or
behavioral problems!
– Psych Problems are typically the result, not the cause!
– Still, stress, especially in 4-6-year-olds (e.g., divorce,
school trauma, sexual abuse, hospitalization)
– Secondary enuresis: limited support
– Family disorganization or neglect
Risk Factors Enuresis
•
•
•
•
Learning disabilities
Lower intelligence
Poor school achievement
Higher rates in ADHD compared to nonADHD
Assessment of Enuresis
• Medical evaluation:
– Urine analysis
– Physical exam
• Family history
• Psychosocial factors
• Child’s perception of enuresis
– Treatment is more successful if child perceives
problem to have psychosocial implications
Assessment of Enuresis
• History of the problem:
– How often and when it occurs
– Type of solutions parents have tried
– Environment issues
• Daily fluid intake
• Bedtime ritual
• Proximity to bathroom
Assessment of Enuresis
Date
Bedtime
Time of
Wakening
Time of
wetting
Size
Parent
Behavior
Treatment:
Spontaneous Remission
• 15% annual rate of spontaneous
remission
• Between the ages of 4 and 6 years:
– 71% of girls stop wetting
– 44% of boys
• Only 38% of children with enuresis seek
medical help
• Less likely if comorbid disorders are
present (e.g., behavior problems)
Treatment:
Daytime/Mixed
Enuresis
•
Education
–
•
http://www.kidney.org/patients/bw/BWkidneyboy.c
fm
Address any emotional/behavioral issues in
therapy
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Family issues
Trauma
Anxiety
Behavior problems
Treatment:
Daytime/Mixed Enuresis
Establish good toileting habits
1. Stop using diapers (exceptions)
2. Recording times child typically goes (every 30
minutes)
•
Child must show regular pattern with intervals
3. Regular sitting – Positive practice
•
•
•
5 minutes at regular times
Make this a positive experience
Use rewards for sitting or toileting
Treatment:
Daytime/Mixed Enuresis
4. Cleanliness training
•
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Matter-of-fact
Cleaning themselves, clothes, floor if wet
Sitting on toilet for 5 minutes after each wet
5. Charting progress and providing rewards
6. Urine “alarm clock”
•
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Reminder/cue
Increase awareness
Treatment:
Daytime/Mixed Enuresis
7.
Sphincter control and urine retention exercises
•
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8.
Not Sufficient Alone
↑ functional bladder capacity (holding urine as long as possible
during the day to stretch bladder – increase liquids during
training)
Sense the “urge”
Strengthen sphincter muscle (stopping urine mid-stream
technique)
Once continence established
•
•
•
9.
Over-learning – increasing fluids
Fade positive reinforcement schedule
If nocturnal bedwetting: treat with urine alarm programs
Other tips:
•
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Diet and exercise
Wait until child is ready
Nocturnal Enuresis Interventions
http://www.kidney.org/news/newsroom/psa.cfm
1. Do nothing: Spontaneous Remission
2. Urine Alarm/Sleep Conditioning
3. Medication
Comparison of Treatment Modalities for Nocturnal Enuresis
C. Carolyn Thiedke, M.D.
American Academy of Family Physicians
Cost for brand
name product
(generic)*
Treatment
Advantage
Disadvantage
Bed-wetting
alarm
Effective, low
relapse rate
Takes weeks for
results; can be
disruptive to family
$50 to $75, plus
shipping and handling
charges
Desmopressin
(DDAVP)
Rapidly
effective, few
side effects
High-relapse rate with
discontinuation
5-ml nasal spray: $149
for 5-mL bottle
0.1-mg tablets: $72 for
30 tablets
0.2-mg tablets: $85 for
30 tablets
Imipramine
(Tofranil)
Inexpensive,
works quickly
High-relapse rate with
discontinuation; side
effects, including
cardiotoxicity at high
doses
25-mg tablets: $28 (8)
for 30 tablets
Treatment:
Nocturnal Enuresis
• Bell-and-pad method or Urine alarm
– Used frequently since 1930
– 75% success rate
– Urine-sensitive pad connected to alarm
– Based on classical conditioning paradigm
• Child learns to associate alarm with feeling of
full bladder
Urine Alarm
Wet-Stop Child Bedwetting Alarm
Urine Alarm
“Alarm systems are the most effective method
for achieving nighttime dryness. A study at the
Mayo Clinic comparing alarms, imipramine,
and a nasal antidiuretic hormone
demonstrated the clear superiority of alarm
systems. A final tally of 261 children followed
for one year showed the cure rate”:
*Alarms used during the test included the
Wet-Stop and the Sears Wee Alert
Reference: J.A. Monda & D.A. Husman,
Journal of Urology,
Volume 154, August 1995
Success Rate
for 12 months
Treatment:
Nocturnal Enuresis
• Bell and pad
– Average use is 6 months
– Increased success through:
• overlearning
• Use of parental reinforcement
• Continuing to use the alarm intermittently
INTENSIVE NIGHT TIME TOILET TRAINING
• The bell and pad (or any other version, (e.g., Wet Stop)
contains an alarm plus a moisture sensitive monitor that is
placed into a little pocket that is sewn inside your child's
underwear. The basic idea is to help your child learn to
awaken when his/her bladder is full, so that s/he can get up
and go to the bathroom at night. Once the habit is
established, the bell and pad can be withdrawn.
What you'll need:
1. Bell and pad or Wet Stops
2. Room in your's and your child's schedule for several
sleepless nights (it might be good to start on a Friday night).
Very intensive training occurs on the first and second night.
3. A logical and gentle rationale for your child (e.g., some kids
are very heavy sleepers and need extra help in waking up to
go to the bathroom at night).
First Night and Second Nights
1.
set up the bell and pad according to instructions
2.
before your child goes to bed, have him/her drink extra fluid
3.
keep yourself within ear shot of the alarm
4.
when the alarm goes off, immediately go into your child's room
and with minimal attention, assist him/her in going to the
bathroom to "finish up."
5.
if your child is of an appropriate age, allow him/her to assist in
the clean up (straightening out the bed, brief washing and
changing pajamas).
6.
have your child practice lying in the bed, getting up to go to the
bathroom several times in a row.
7.
encourage your child to drink more fluid before going back to
sleep
Third Night through 2nd week
1.
all steps above are in place EXCEPT do not encourage
additional fluids.
2.
provide your child with rewards for each dry morning
3.
your therapist will help you establish when to fade out the use of
the bell and pad.
After 14 Consecutive Dry Nights: Overlearning
1. Child drinks 6-8 ounces of favorite liquid (non-caffeinated)
before bedtime
2. Some accidents are expected
3. Continue until 14 more consecutive dry nights
Intermittent Schedule
1. Tell your child that on some nights the parents will disconnect
the alarm after he/she has gone to sleep
2. Since they will not know when it is connected, this will help
him/her to learn to sleep through the night without the alarm
3. During the next week, disconnect alarm 2 nights, and then
increase the number of nights disconnected after each
completely dry week until the alarm is no longer connected
If wetting occurs more than once a month for 2 months, use the
alarm again until the child has 30 dry nights in a row
Encopresis
Definition and DSM Criteria
• Repeated passage of feces into
inappropriate places
• 1x/month for 3 months
• Chronological/mental age of 4 years
• 2 DSM Subtypes:
– With constipation and overflow incontinence
(retentive: due to chronic constipation)
– Without constipation and overflow
incontinence (nonretentive)
Encropresis
Nonretentive subgroups
1. Primary: failed to obtain initial bowel
training
2. Toilet Fears: Avoidance
3. “Manipulative”: used by child to control
the environment – ODD??
4. Irritable Bowel Syndrome
Encopresis:
Prevalence
• Less researched than enuresis
• ~ 25% of encopretic kids have enuresis
• 1.5%-7.5% of children aged 6-12
– 5x more common in boys
– 80-95% involve fecal constipation and retention
• Associated physical symptoms:
– Poor appetite
– Abdominal pain
– Lethargy
Encopresis:
Etiology
• Biological factors may play a role
• Emotional factors alone do not usually
account for onset of retentive
• Learning factors:
– Deficits in toileting skills (recognizing bodily cues,
undressing, etc.)
– Chronic constipation may lead to loss of previously
learned toileting skills
– Soiling may be reinforced by environmental factors
Encopresis:
Etiology
• Learning factors, continued:
– Stress or anxiety may lead to loss of
previously learned toileting behaviors
– Developed fear of toileting due to:
• Painful bowel movements
• Aggressive toilet training or severe punishment
for accidents
• Fear of toilet
– Other factors: poor diet, embarrassment,
poor access, inconsistent schedules
Encopresis:
Etiology
• Emotional factors:
– Historically, psychodynamic approaches
have viewed encopresis as a sign of
underlying emotional distress
– Encopretic children display more behavior
problems and more family problems
– Nonretentive encopresis and secondary
encopresis can be associated with
Oppositional Defiant Disorder or Conduct
Disorder
Encopresis Assessment
• Medical assessment is warranted:
– Impaction
• Gather information about:
– Stressful life events
– Toilet training history
– Psychological/behavioral difficulties
– Typical family routine
– Child and parent perceptions of problem
Encopresis:
Treatment
• Not as well researched as enuresis
• Intervention modalities:
– Education
– Biofeedback
– Behavioral
– Medical
Encopresis:
Treatment
• Medical and Educational approaches:
– Diet and exercise (e.g., high fiber diet,
fluids)
– Laxatives or enemas
• Behavioral
– Reinforcement, overcorrection, skillbuilding techniques
• Biofeedback:
– Muscle strengthening/relaxing exercises
Encopresis:
Treatment
• Schroeder & Gordon (2003)
“plumbing problem” conceptualization
• Education:
– Information about the GI tract and it’s
functioning
– Information about diet and exercise
• Medical Interventions:
– Enema for impaction and laxatives
Encopresis:
Treatment
• Toileting Skills:
– Sitting schedules (for 5-10 minutes 20
minutes after meals)
– Reinforcement for sitting and using the
toilet
– “Clean pants check”
• Reward if clean
• Child helps clean up if dirty
Why is Sleep Important for you to
know about?
• Children with depression, anxiety, behavior problems, and
ADHD have ↑ risk for sleep problems
• Sleep disturbance (e.g., sleep-disordered breathing, sleep
restriction, fragmented sleep) is associated with worse
neuropsychological (attention, executive functioning, motor
skills, reaction time performance), behavioral (increased
hyperactivity, inattention, impulsivity, conduct problems),
and emotional (anxious/depressive symptoms, withdrawal,
somatic complaints) functioning (Archbold et al., 2004;
O’Brian et al., 2004; Fallone et al., 2000; Owens et al.,
2000; Owens, 2005)
• 37% of children kindergarten -4th grade suffer from at least
1 sleep-related problem (www.sleepfoundation.org)
Sleep Disturbances in Children
• Young children with sleep problems
tended to have problems 3 years later
• Of 8-year-olds with sleep wakening
problems, 40% had sleep problems at
age 3
• Evidence suggests that sleep problems
do not “go away”
Basics of Sleep - Stages
• REM - Dreaming, brains “active”, body immobile
• NREM - “quiet”, deep “restorative” stages associated with
tissue growth/repair, hormones released for development
Basics of Sleep – REM
• Younger children have somewhat different patterns of
sleep than adults, but typically develop a normal adult
cycle by 8 years
• http://www.sleepfoundation.org/doze/
Developmental
Sleep Requirements
AGE
TOTAL/DAY
PERIODS
Early infancy
16 hours
2-4 hours
12 months
14 hours
8-12 hrs, 2 naps
24 months
13-14 hours
11-12 hrs, 1 nap
3 years
12-13 hours
11-12 hrs, 1 nap
5 years
11 hours
No naps
10-12 years
10 hours
No naps
BEARS – Assessment
Simple set of sleep questions for parents
B= Bedtime
• Does your child have difficulty going to bed? Falling
asleep?
E= Excessive daytime sleepiness
• Is your child always difficult to wake up in the
morning?
• Does your child seem sleepy or groggy during the
day?
• Does he or she often seem overtired (this can mean
moody, "hyper," or "out of it" as well as sleepy)?
BEARS – Assessment
Simple set of sleep questions for parents
A= Awakenings during the night
• Does your child wake up at night? Have trouble falling
back to sleep?
• Does anything else seem to interrupt his sleep?
R= Regularity and duration of sleep
• What time does my child go to bed and get up on
weekdays? Weekends?
• How much sleep does he or she get? Need?
S= Snoring
• Does your child snore? Loudly? Every night? Does he
ever stop breathing or choke or gasp during sleep?
Common Sleep Disturbances in
Children
• Common Bedtime problems:
– Initiating sleep
– Maintaining sleep (Sleep interruption)
– 20-30% of children ages 1-5
• Treatment can include pharmacological
approaches or behavioral approaches
Sleep Disturbances in Children
• Parents of 5 to 12-year-olds reported
the following sleep problems:
– Bedtime resistance (27%)
– Problems waking up (17%)
– Fatigue (17%)
– Sleep-onset delays (11%)
– Night waking (6.5%)
Sleep Disturbances in Children
Parasomnias
• Disruptions during sleep or at the transition from
sleep to wakefulness
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Nightmares (REM), Very common
Sleep Bruxism, >50% normal infants, 15% ages 7-17
Sleep Walking (~Stage 4 NREM), 18.5% ages 9-12
Sleep Terrors (NREM- early) 1-6 %, preschool age
Sleep Talking (REM or NREM), 50-60%
Others: REM Sleep Behavior Ds, Sleep Rocking, Head
Banging, Sleep Paralysis, Partial Arousals
• 20% of children experience at least one of these
(Ware et al., 2001)
• Generally etiology is unclear
• Tend to disappear with age/maturation
Sleep Disturbances in Children
• Treatment for recurrent nightmares:
– At night:
• Have child describe nightmare
• Use a night light
• Reassuring child
– During day:
•
•
•
•
Desensitization (e.g., drawing)
Replaying the nightmare
Using pleasant imagery or teaching relaxation
Using positive self-statements
Sleep Disturbances in Children
Obstructive Sleep Apnea
• Pauses in breathing during sleep
• Momentary wakening/arousals may not allow
entrance into deep NREM stages and may
reduce REM
• Symptoms
– Loud snoring, restless sleep, daytime sleepiness
• Associations
–  tone of or enlarged tonsils or adenoids
– Obesity
Sleep Disturbances in Children
Narcolepsy
• Sleep distributed across 24 hours
– Night-time sleep interruptions + short periods of uncontrollable
daytime sleepiness
– REM based disorder
• Often 1st noticed in puberty, but occurs as young as 10
• Symptoms
– Daytime “sleep attacks”, cataplexy (loss of tone), inability to
move after waking, dream-like imagery before falling asleep
• Etiology
– Neurological with strong genetic link
– 18X risk if 1st degree relative
– 3/10,000 European Americans
Sleep Disturbances in Children
Periodic Limb Movement Disorder & Restless
Leg Syndrome
• RLS
– Sensations deep in the legs produced by an irresistible
urge to move
– Bothersome but not painful
– Worst when at rest
– Problems initiating & maintaining sleep
• PLMD
– Leg movements/jerks every 20-40 seconds during sleep
– Disrupt sleep
• Etiology: Iron or Vitamin Deficiency
Sleep Disturbances in Children
Excessive Daytime Sleepiness
• Multiple Causes
– Narcoplepsy, sleep apnea, restless leg syndrome,
medication, illness, depression, etc.
• Symptoms:
– Sleeping 2 hours + than typical child
– Short attention span, poor coordination, irritability,
forgetfulness
Sleep Interventions
• Medical and/or Behavioral
–Medications
–Tonsilectomy
–Weight Loss
–Sleep Hygiene
Sleep Hygiene Recommendations
used for 2-3 year old
The following are pediatric sleep hygiene guidelines
put forward by the National Sleep Foundation
(www.sleepfoundation.org)
• XXX should follow a nightly routine. A bedtime
ritual makes it easier for your child to relax, fall
asleep and sleep through the night.
–
For example, a typical bedtime routine may involve:
1. light snack. 2. Take a bath. 3. Put on pajamas. 4.
Brush teeth. 5. Read a story. 6. Make sure the
room is quiet and at a comfortable temperature. 7.
Put child in bed. 8. Say goodnight and leave.
Sleep Hygiene Recommendations
used for 2-3 year old
• Make bedtime a positive and relaxing experience
without TV or videos. TV viewing prior to bed can
lead to difficulty falling and staying asleep. Save your
child's favorite relaxing, non-stimulating activities until
last and have them occur in the child's bedroom.
• Encourage children to fall asleep on their own.
Have your child form positive associations with
sleeping. The child who falls asleep on his or her own
will be better able to return to sleep during normal
nighttime awakenings and sleep throughout the night.
Sleep Hygiene Recommendations
used for 2-3 year old
• Make bedtime the same time every night,
and get up at the same time each morning,
even on weekends. This helps the body
acquire a consistent sleep rhythm.
• Adjust the total sleep time to fit your child's
age and needs. It is recommended that XXX
obtain between 12 and 14 hours of sleep.
Sleep Hygiene Recommendations
used for 2-3 year old
• Your child should sleep in a cool room; avoid
temperature extremes. Keep the bedtime
environment (e.g. light, temperature) the same all
night long.
• Your child should sleep in the same room
consistently, not in a room utilized for most wake-time
activities. Do not allow your child to use the bed for
anything but sleep - do not watch TV or eat in bed.
Do not use "going to bed" as a punishment.
• You may wish to plan regular daily exercise for your
child, preferably in the evenings using the leg and
arm muscles but do not exercise for thirty minutes
prior to bedtime.
Sleep Hygiene Recommendations
used for 2-3 year old
• Encourage your child to avoid heavy meals within
two hours of bedtime; however, a light snack such
as milk or cheese or crackers at bedtime may be
helpful. Do not give excessive fluids prior to bedtime.
• Allow your child to have no stimulants within eight
hours of bedtime (no cola drinks, tea, coca,
chocolates; etc.)
• If your child has troublesome recurrent thoughts
disturbing sleep onset; write them down with
appropriate plan of action. Encourage them to think
about simpler less troubling matters, recite rhymes,
or think of songs.
Sleep Hygiene Recommendations
used for 2-3 year old
• Discourage nighttime awakenings. When parents
go to their child's room every time he or she wakes
during the night, they are strengthening the
connection between you and sleep for your child.
Except during conditions when the child is sick, has
been injured or clearly requires your assistance, it is
important to give your child a consistent message
that they are expected to fall asleep on their own.
Provide your child with a lot of verbal praise for falling
asleep on their own.
• Accept occasional nights of sleeplessness as
being normal.
Sleep Hygiene Recommendations
used for 2-3 year old
• For young children, nap and nighttime sleep
are both necessary and independent of each
other. Children who nap well are usually less
cranky and sleep better at night. Although
children differ, after six months of age, naps
of 1/2 to two hours duration are expected
and are generally discontinued between
ages 2-5 years. Daytime sleepiness or the
need for a nap after this age should be
investigated further.
Eating Difficulties
• Eating or mealtime difficulties occur at
some point in almost all children
• Children generally have control over
their eating
• 20-62% of children having eating
problems brought to the attention of a
professional
Eating Difficulties
• Classification systems (e.g., DSM),
especially for early eating problems,
generally do not exist
• One classification system:
– Developmental appropriateness of foods
– Quantity consumed
– Mealtime behaviors
– Delays in self-feeding
Typical Development of
Eating Behaviors
• Birth – 2 months: infants are feed as
often as needed
• 3-5 months: children begin eating solid
foods, can learn to accept most new
tastes
• 7-10 months: children feed themselves
with fingers or begin using spoon,
“critical period” for introducing solids
Typical Development of
Eating Behaviors
• 9-10 months: drinks from cup with
spout, brings spoon to mouth
• 15 months: self-feeding
Promoting Positive Eating
Practices
• Rejection of new foods is very common,
but can be overcome with repeated
trials
• Parent control of mealtimes may lead to
coercive patterns and eating problems,
weight fluctuations, and food
preoccupation
• Children should be allowed make their
own choices (to a degree)
– Innate regulatory system
Mealtime Rules
1.
2.
3.
4.
5.
6.
7.
Remain seated
Chew and swallow with mouth closed
Use utensils
Include children in conversation
Reward appropriate behavior
Remove food at end of meal
Allow snacks only if food was consumed
during meal
8. Time out for rule breaking or disruptive
behavior
(Christophersen & Hall, 1978)
Eating Problems:
Pica
• Pica-persistent eating of nonnutritive
substances for a period of at least 1
month
– Dirt, paint chips, soap, plaster, chalk
• Considered problematic if persists past
18 months
• Most common in individuals with
developmental disabilities, MR, and
children between 2-3 years
Pica
• Etiology: nutritional deficiencies,
parental neglect, impoverished
environment, lack of stimulation
• Treatment:
– Parent education
– Behavior therapy
• Overcorrection
• Rewarding other behaviors
Rumination
• Intentional and repeated regurgitation of
food
• Not associated with a medical problem
• This is developmentally appropriate in
children < 6 months
• Important to assess parent-child
interactions
Failure to Thrive
• Child’s weight falls below normal
– >2 S.D. below mean for age
– Gestational age, parents, gender
• Characterized by an interplay between
environmental and physical problems
– Continuum rather than FTT vs. Non-Organic FTT
• 3.5-35% of children
• Typically occurs in infants, but also in
preschoolers
Failure to Thrive
Risk Factors
• Caregiver:
– Poor nutrition knowledge
– Improper feeding techniques
– Depression or psych distress
– History of inadequate parenting as a child
– Poor problem solving
Failure to Thrive
• Infant risk factors:
– Prematurity
– Difficult temperament
– Depression
– Physical Illness
Failure to Thrive
• Environmental risk factors
– Poor financial resources
– Lack of social support
– Poor-quality home environment
– Being youngest in large family
Failure to Thrive
• Treatment is multidisciplinary in nature
– Medical professionals, psychologists, social
workers
– At-home visits after inpatient stays
– Education
• Observation of parent-infant interactions at
mealtimes is important
• Weekly visits during pregnancy in high-risk
mothers can be successful in preventing FTT
Any
Questions?