1. Introduction to Behavioral Pediatrics Jodi Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute University of Nebraska Medical Center

2. Overview Encopresis Enuresis An empirically-supported approach to day time toilet training An empirically-supported approach to night time toilet training

3. Encopresis Repeated passage of feces into inappropriate places whether involuntary or intentional At least one such event a month for 3 months At least 4 years old Not due to direct effects of substance or medical condition except constipation With constipation and overflow incontinence Without constipation and overflow incontinence

4. Encopresis Medical Workup/Management Bowel habits assessment Education Diet assessment/Changes Compliance/Behavioral protocol

5. Encopresis Medical Workup/Management Assessment of etiology Slow moving bowels vs. Spina Bifida or Hirschsprung’s disease If constipation – “clean out” Laxatives, stool softeners, or fiber for maintenance

6. Encopresis Medical Workup/Management Bowel habits assessment

8. Encopresis Medical Workup/Management Education Symptoms of constipation Functioning of bowel Behavioral “causes” Diet

10. Encopresis Medical Workup/Management Education Diet assessment/Changes Diet diary Behavioral protocol to increase fiber Premack principle

12. Encopresis Medical Workup/Management Education Diet assessment/Changes Behavioral Protocol (to be discussed)

13. Enuresis Repeated voiding of urine into bed or clothes (whether involuntary or intentional) Behavior is clinically significant (at least 2x/wk for 3 mos or causes impairment) At least 5 years old (developmentally) Not due to substance/medical condition

14. Enuresis Primary vs. secondary Nocturnal vs. diurnal

15. Enuresis Medical evaluation Assessment of compliance Behavioral protocol

16. First time toilet training Among top concerns expressed by mothers on internet, call-in services Most frustrating Lots of “lore”

17. First-time toilet training Passive “child-oriented” Brazelton, 1962 Physical maturity, interest, and “psychological readiness” “relax, be patient” Intensive “toilet-training in a day” Azrin & Foxx, 1974 Physiological readiness and compliance Principles of operant conditioning

18. Empirically supported toilet training Thinking time question #1a: How could you provide a child with lots of practice in toileting?

19. Empirically supported toilet training Thinking time question #1a, b: How could you provide a child with lots of practice in toileting? How could you provide predictabilty in structuring programming?

20. Empirically supported toilet training Thinking time question #1a, b, c: How could you provide a child with lots of practice in toileting? How could you provide predictabilty in structuring programming? How could you provide a high contrast to help skill acquisition?

21. Empirically supported toilet training Toilet Training in a Day (Azrin & Foxx) Repetition Fluid load Frequent toilet sits Pants checks

22. Empirically supported toilet training Toilet Training in a Day (Azrin & Foxx) Repetition Fluid load Frequent toilet sits Pants checks High Contrast Rewards for compliance with sits, successful voiding in toilet, and dry pants Clean-up and overcorrection for wetting

23. Empirically supported toilet training Toilet Training in a Day (Azrin & Foxx) Repetition Fluid load Frequent toilet sits Pants checks High Contrast Rewards for compliance with sits, successful voiding in toilet, and dry pants Clean-up and overcorrection for wetting Predictability Consistent schedule for toilet sits/pants checks Star chart with grab bag Use of attention

24. Empirically supported toilet training Institutionalized incontinent adults Typically developing children with toileting resistance Mass audience of first-time learners

26. Empirically supported toilet training Thinking time question #2: What if the child refuses to sit on the toilet?

27. Encopresis Thinking time question #3: What would be a good behavioral protocol for a child who is soiling daily after school?

28. Enuresis Thinking time question #4: What would be a good behavioral protocol for a child who is wetting daily at daycare?

29. Empirically supported treatment for nocturnal enuresis Assessment Education Urine alarm Support to maintain integrity

30. Empirically supported treatment for nocturnal enuresis Assessment Education Prevalence Medication vs. Urine alarm

31. Empirically supported treatment for nocturnal enuresis Assessment Education Urine alarm Overlearning Dry-bed training Arousal Training Reward for waking to moisture alarm

33. Empirically supported treatment for nocturnal enuresis Assessment Education Urine alarm Support to maintain integrity

34. Nocturnal enuresis Thinking time question #5: What if the child won’t wake to the alarm?

35. Nocturnal enuresis: Trouble shooting “Darren” 13 year-old Caucasian male No medical, psychiatric, academic history or concerns Life-long history of bedwetting Two, one-year trials with moisture alarm. Currently treated with DDAVP

36. Darren Number of Wet Beds Per Week

37. Darren Number of Times Mom Intervened At Night

38. Darren: Treatment Plan Sleep assessment: Rule out apnea Operant training: Wake to alarm Maintenance: Medication, no alarm

39. Darren: Treatment Plan Arousal Training Familiar, loud, clock-radio. Contingency for success. Two alarms per night.

40. Darren: Treatment Plan Alarms Week 1: 5:00 a.m. and 7:00 a.m. Week 2: 5:15 a.m. and 6:45 a.m. Week 3: 5:30 a.m. and 6:30 a.m. Week 4: 6:00 a.m. Week 5:6:00 a.m. Week 6:6:30 a.m.

41. Darren Number of Wet Beds Per Week

42. Darren Number of Times Mom Intervened At Night

43. Darren Frequency of Self-Waking to Toilet

44. Darren Number of Wet Beds Per Week

45. Darren Frequency of Self-Waking to Toilet

46. Darren Number of Wet Beds Per Week

47. Darren: Conclusions Practice with waking to scheduled alarms: improved independence. increased frequency of self-waking to toilet. increased frequency of sleeping through night dry. supplemented medication therapy.

48. Trouble Shooting Arousal Problems Evaluation for sleep disorder, particularly apnea. Programmed alarms for “easy” times and phase to time when urinating likely. Programmed alarms for times when urinating likely and phase toward morning. Supplement behavioral intervention with medication. Use of familiar “alarm clock” gives volume control/replaces moisture alarm.