it0970-EarlyChildhoodBehaviourProblems(continued).ppt

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1、Early Childhood Behaviour Problems(continued)Child Assessment&Therapy:512-924October 2007Gaining control of bladder&bowelNormal developmentnInfants:urinate often,small amounts,reflexn1-2 years:child notices full bladder,void less often,larger amountsnAge 3:child holds for longer periods,can get to t

2、oiletnPreschooler often cannot empty bladder unless it is full(eg cant go before a car trip on request)n20 24 months a good age to begin in normally developing child.Older age,easier to learnnSigns of readiness:lBeing able to sit on potty or toilet seat(coordination)lAble to understand simple instru

3、ctions,cooperativelAble to hold urine for 1-2 hours without leakagelRegular bowel movements,no soiling during sleepnSummer easier in cold climatesnAvoid times of stress(eg birth of sibling)Toilet trainingnEvery Parent(Sanders):active teaching,using doll as modelnToilet training,Bedwetting and Soilin

4、g(Herbert,PACTS series):more gradualnManaging Problem Behaviours(Dodd)Ways of toilet trainingAll approaches emphasize importance of:nNo undue pressure,calm,matter of fact approachnMinimal attention and no negativity about mistakesnPositive attention for success(praise,maybe stickers)(Remember age of

5、 child:tends to be oppositional!)Principles of toilet trainingUseful suggestionsnIncrease fluid to increase rate of learningnOnce not in nappy at home,remove nappy altogethernPlastic sheet covered with towel for car seatnTake potty everywhere initiallynKeep child in uncarpeted areas nBoys to sit dow

6、n initially,learn to stand laterIntellectual,physical disabilities:nSimilar issues of readiness(likely to be older)nMore specific training,based on careful observation and monitoring of childs current routine of eating/drinking;elimination,routines;behaviours prior to eliminationnRole of occupationa

7、l therapists where physical difficultiesToilet training children with disabilitiesAutism Spectrum Disorder issues of:nCommunicationnSensory issuesnPreference for routine,difficulty adjusting to new behavioursnMotor planning difficultiesnDifficulty imitatingnSequential learning:(identify how the chil

8、d learns best)nAnxiety levelsToilet training children with disabilitiesNocturnal enuresis:bedwetting in a child over 5 years(or equiv.developmentally)Diurnal enuresis:wetting during the day in children 5 years and overPrimary enuresis:where a child has never been dry longer than 6/12 monthsSecondary

9、 enuresis:children who have been dry longer than 6/12 months&begin wetting againEnuresis:terminology%bed-wetting at different ages(variable figures depending on definition of bed-wetting)Age in years345678914%who wet the bed2015 12 (15-20)12 8 (7)65 4 (15 yr 1-2%)nMore boys wet beds than girlsnSeek

10、help at ages 5 7 yearsnOften a family history of bed-wetting:geneticnDevelopmental delaynEmotional stresses may lead to secondary enuresis(but rarely severe emotional problems)nMedical reasons occasionally(eg urinary tract infection,epileptic seizures,central nervous system or bladder)Causes of enur

11、esisnHigh production of urine at night,associated with insufficient arginine vasopressin(avp)release at night(Wetting soon after going to bed,large wet patches)nSmall functional bladder capacity(fbc)associated with bladder overactivity.(Nighttime:multiple bedtime wettings,small wet patches)nPossibly

12、 a difficulty with arousal from sleep when bladder reaches its maximum capacity(Butler&Holland 2000)Causes of enuresis(continued):The Three-Systems ModelnEducational,simple strategiesnRefer to specialist or clinicRole of PsychologistnNeed medical review to exclude bladder infections,constipation,ren

13、al problems nMonitor nighttime wetting(frequency,timing,amount,etc)nMeasure functional bladder capacity if seems indicatedAssessment(and clinical interview)nEncouragement and reinforcementlKeep a record of wet and dry bedslReward(small and as soon as possible after the dry bed)lNot suitable for a ch

14、ild who invariably wets:too difficult and demoralisingnToilet routine:practice getting out of bed and going to toilet a number of times,make sure easy accessnLifting,fluid restriction before bedtime:not effectivenCaffeinelSome studies suggest eliminating caffeine from diet helpfulForms of treatmentn

15、Bladder stretching exercises (if child is passing urine often and in small amounts)nControl training:helps children gain more control over their muscles by stop and start flow of urine when using toiletForms of treatment(where bladder overactivity,frequency of urination)nScheduled waking if wets at

16、same time each nightnBell and Pad(bedwetting alarm;pad&buzzer)Cochrane review of 52 trials:lAbout 2/3 became dry during alarm usel50%remained dry after treatmentlRelapse rates reduced when over-learning(giving extra fluids at bedtime once successfully dry)occurredlMore effective than medicationsNB H

17、igher rates of success reported in other studies.More children successful if have second trial.Forms of treatment(where lack of avp release&difficulty arousing with full bladder)nDesmopressin(also called Minirin)is a synthetic hormone which concentrates the urine.Safe and free of side effects.Used a

18、t RCH for children who do not become dry with the alarm.nAnticholinergics for bladder overactivitynTricyclics such as Imipramine,poor efficacy,side effectsDrug treatment on its own is rarely an effective long-term treatment,high rates of relapseForms of treatment(Medication)Complex behavioural inter

19、ventions(eg Dry Bed Training:DRT,Azrin,1973):nDeveloped for adults with intellectual disabilitiesnDemanding procedurenAlarm seems to be the effective componentnNowadays eliminate reprimands and positive practice elementsForms of treatment(continued)Different aetiology to nocturnal enuresis:Organic c

20、auses:structural abnormalities and functional disorders of the urinary tractDaytime EnuresisAn inability to control the bowel fully,resulting in soiling:nPrimary faecal incontinencenSecondary:have gained control and lose itBehavioural/emotional issues(not encopresis):play with or smear faeces;choose

21、 to soil in pants.Encopresis“Learning to go to the toilet is not a particularly difficult task,and in our culture is usually accomplished about age two.The failure of children age four and above to exhibit this skill elicits intense emotions both in parents and professionals.The distress of the chil

22、d and family are all too apparent.”(Baglow,1987)Can be a battleground:need to form a team.EncopresisnIn most cases,a result of prolonged constipation leading to stretched muscles in the bowel which cannot send messages reliably to the brain and cannot contract reliably(retention&overflow)nAnal fissu

23、re,and other reasons leading to pain associated with defecationnIntellectual or physical disabilitiesnSocial:neglectful or coercive toiletingPrimary CausesnFrequency,type and timing of soilingnMemories of painful experiences trying to defecatenDevelopmental level of child,medical issuesnToilet train

24、ing,in particular bowel training methods and timingAssessmentnParent-child relationship,separation issuesnQuality of marital relationshipnPersonality of parents,psychological state of parent(eg depression),parents own childhood experiencesnStressors Careful analysis of all factors choice of treatmen

25、tAssessment(continued)Medical/dietary treatmentlMay need enema if constipated with a mass of faeceslOn-going treatment of constipation lmotivation of childldaily routine(sit on toilet 5-10 minutes 20 minutes after breakfast,perhaps after other meals)lfibre&fluid in dietlexerciselon-going laxatives f

26、or a whileTreatmentBehavioural(where original factors leading to encopresis have vanished)nStar chart,reward schemenSneaky Poo(White,1984;Heins&Ritchie,1985,1988):externalising of the problem,forming a team to fight it,using planning and practice to prepare,and increasing motivation partially throug

27、h telling othersTreatment(continued)Parent Counselling:nEducation about digestion and defecation.nManagement of practical matters(diet,regular toileting programme)nHear the parents emotional responses(often anger)relating to the soiling.nDiscouragement of punitive response.Treatment(continued)nFamil

28、y Therapy:enmeshment,overprotectiveness,rigidity,lack of conflict resolution:general family organisation and functioningnPsychotherapy for the child:where simple behavioural approaches not possible,nor family therapyOther TherapyCase StudyMajor theoriesnSocial learningnAttachment TheorynFamily syste

29、ms theory(especially structural)nCognitive/attributional theory nEcological ModelFeeding difficultiesInterplay of biological,organic,emotional,relationship and social learning factorsFactorsnInability to read childs cues of hunger and satietynBeliefs about appropriate eating(eg ethnicity)nLack of pr

30、ovision of pleasant eating environment:chaotic/disorganised(TV,toys)nInability to model appropriate eatingnInability to shape learning independent feedingnOver-concern with feeding challenges of toddlerhoodFactors:social env,parentingnIrritabilitynLack of responsivenessnSensory issuesnOppositional b

31、ehaviourFactors:child characteristicsnCleft palatenRefluxnSwallowing difficultiesnCystic fibrosisInvolvement of Speech Pathologist if oro-motor factors involved in swallowing.Factors:organic,biological25-35%of pre-schoolers have feeding problems:nSelective eating of types of foodnLittle eating,picki

32、ng through the daynRefusal to eat new foods(neophobia)Types of Feeding ProblemsnDelay in learning to feed selfnPace of feeding:too slow or gorgingnDisruptive at tablenRumination,vomitingnFood refusal,failure to thrive(below 3rd percentile for body weight)Types of Feeding ProblemsMany causes:nOrganic

33、(inadequate nutrition,malabsorption,chronic infection,major structural congenital abnormalities,metabolic and endocrine defects)nNon-organic,associated with some deficit in nurturance and physical intimacy(see Iwaniec,1995,re treatment)Failure to ThrivenPattern of eating and associated behaviour(Foo

34、d diary)nHeight and weight informationnMedical/developmental factorsnHistory of pain associated with eatingnInteraction with parent,especially around eatingnFamily factorsnEmotional factors(anxiety,depression)AssessmentResearch indicates that it takes a good deal to interrupt a childs natural tenden

35、cy to accept and regulate food intake.Meal by meal intake can vary,but energy intake tends to remain fairly constant.Therefore:lProvision of appropriate food is parents rolelLeave the child to manage their intakeSocial context of meals:nFamily mealtimes,routine and consistency nPositive env:praise/a

36、ttention for appropriate behnLimits placed on inappropriate beh:ignored,natural consequence(removal of food),time outnModelling of enjoyable eating by parentsnNot too many distractions(TV,phone,etc)Early steps to establishing mealtimes as pleasantnMatching amount of food to appetite,allow child to d

37、etermine his own intakenControl of food intake between meals(other than designated snacks)Parent responsiveness to childs eating cuesnRepeated exposure(up to 10 times)to novel foods to improve acceptancenMaking positive statements to encourage a child to taste novel or new foods:“Would you like to t

38、ry it?It tastes good.”Encouraging range of foodnForming a team with the parents to work together and decide on the interventionnEncourage participation of childnNutritional help,psychoeducationnReassurance,building on strengthsnConfidence buildingPlus:Feeding Disorders Project(Karen Turner,Matt Sand

39、ers,UQ,early 1990s)nBehavioural Parent TrainingnManuals in Dept Psych RCH or available through Parenting and Family Support Centre,School of Psychology,University of QueenslandFeeding Disorders ProgrammesPaediatric Feeding Disorders Program(Kennedy Krieger Institute,Baltimore,Maryland,USA)nCombination of gastroenterology with behavioural psychology to establish feeding patterns with nutritional value across all environmentsnWeekly outpatient clinic,day treatment program,inpatient program(8-12 patients at a time,average stay 6-7 weeks)Feeding Disorders Programmes