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Title: Common%20Childhood%20Problems


1
Common Childhood Problems
  • Psy 4930
  • September 12, 2006

2
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?

3
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

4
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 gt26 months, 2X faster
    than if lt24 months

5
Toilet Training
  • Readiness
  • Bladder Control
  • Voluntarily control sphincter muslces
  • Dry for several hours
  • Gross motor milestones
  • Walking, holding objects independently
  • Language milestones
  • Receptive 1 and 2-step commands
  • Expressive communicate needs
  • Desire to control the impulse to urinate or
    defecate

6
Treatment Options
  • Retention Control Training
  • Rewarding child for increasing periods of urine
    retention over 2 week period
  • Supportive approaches
  • Education
  • Fluid restriction
  • Night Awakening

7
Case 3-year-old is experiencing difficulty with
toilet-training for bowel and bladder.
Behavioral program for intensive daytime toilet
training
  • 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.
  • Have XXX sit on the toilet for 5 minutes every
    half hour.
  • If she urinates (even a little bit) or moves
    his/her bowels
  • Give lots of praise and applause!!!
  • Give candy immediately (keep candy in the
    bathroom so it can be given quickly)
  • 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).

8
  • If she has an accident... do Positive Practice
  • Physically guide her to the bathroom
  • Give reminder in a neutral voice "wet pants are
    bad or oops, youre wet (avoid further
    conversation)
  • Guide her to pull down pants
  • Guide her to sit on the toilet (just sit for a
    couple seconds)
  • Guide her to stand and pull pants up
  • Guide her back to the area where you originally
    discovered the accident, and say
  • Now its 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.

9
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."

10
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.

11
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

12
Enuresis
  • Classifications of enuresis
  • Nocturnal - only during sleep
  • lt10 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

13
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
  • 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

14
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
  • Hyperactivity
  • Behavior problems
  • Anxiety
  • Developmental delays
  • Learning disabilities

15
Etiology of Enuresis
  • Biological Organic Urinary Incontinence (1-3)
  • 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

16
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, self-control)

17
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

18
Risk Factors Enuresis
  • Learning disabilities
  • Lower intelligence
  • Poor school achievement
  • Higher rates in ADHD compared to non-ADHD

19
Assessment of Enuresis
  • Medical evaluation
  • Urine analysis
  • Physical exam
  • Family history
  • Psychosocial factors
  • Childs perception of enuresis
  • Treatment is more successful if child perceives
    problem to have psychosocial implications

20
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

21
Assessment of Enuresis
Date Bedtime Time of Wakening Time of wetting Size Parent Behavior




22
TreatmentSpontaneous 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)

23
Treatment Daytime/Mixed Enuresis
  • Education
  • http//www.kidney.org/patients/bw/BWkidneyboy.cfm
  • Address any emotional/behavioral issues in
    therapy
  • Family issues
  • Trauma
  • Anxiety
  • Behavior problems

24
Treatment Daytime/Mixed Enuresis
  • Establish good toileting habits
  • Stop using diapers (exceptions)
  • Recording times child typically goes (every 30
    minutes)
  • Child must show regular pattern with intervals
  • Regular sitting Positive practice
  • 5 minutes at regular times
  • Make this a positive experience
  • Use rewards for sitting or toileting

25
Treatment Daytime/Mixed Enuresis
  • Cleanliness training
  • Matter-of-fact
  • Cleaning themselves, clothes, floor if wet
  • Sitting on toilet for 5 minutes after each wet
  • Charting progress and providing rewards
  • Urine alarm clock
  • Reminder/cue
  • Increase awareness

26
Treatment Daytime/Mixed Enuresis
  • Sphincter control and urine retention exercises
  • 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
  • Over-learning increasing fluids
  • Fade positive reinforcement schedule
  • If nocturnal bedwetting treat with urine alarm
    programs
  • Other tips
  • Diet and exercise
  • Wait until child is ready

27
Nocturnal Enuresis Interventions
http//www.kidney.org/news/newsroom/psa.cfm
  1. Do nothing Spontaneous Remission
  2. Urine Alarm/Sleep Conditioning
  3. Medication

28
Comparison of Treatment Modalities for Nocturnal
Enuresis C. Carolyn Thiedke, M.D. American
Academy of Family Physicians
Treatment Advantage Disadvantage Cost for brand name product (generic)
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 bottle0.1-mg tablets 72 for 30 tablets0.2-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
29
TreatmentNocturnal 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

30
Urine Alarm
Wet-Stop Child Bedwetting Alarm
31
Urine Alarm
Success Rate for 12 months
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
32
TreatmentNocturnal Enuresis
  • Bell and pad
  • Average use is 6 months
  • Increased success through
  • overlearning
  • Use of parental reinforcement
  • Continuing to use the alarm intermittently

33
  • 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
  • Bell and pad or Wet Stops
  • 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.
  • 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).

34
  • First Night and Second Nights
  • set up the bell and pad according to instructions
  • before your child goes to bed, have him/her drink
    extra fluid
  • keep yourself within ear shot of the alarm
  • 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."
  • 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).
  • have your child practice lying in the bed,
    getting up to go to the bathroom several times in
    a row.
  • encourage your child to drink more fluid before
    going back to sleep
  • Third Night through 2nd week
  • all steps above are in place EXCEPT do not
    encourage additional fluids.
  • provide your child with rewards for each dry
    morning
  • your therapist will help you establish when to
    fade out the use of the bell and pad.


35
  • After 14 Consecutive Dry Nights Overlearning
  • Child drinks 6-8 ounces of favorite liquid
    (non-caffeinated) before bedtime
  • Some accidents are expected
  • Continue until 14 more consecutive dry nights
  • Intermittent Schedule
  • Tell your child that on some nights the parents
    will disconnect the alarm after he/she has gone
    to sleep
  • Since they will not know when it is connected,
    this will help him/her to learn to sleep through
    the night without the alarm
  • 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

36
EncopresisDefinition 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)

37
Encropresis
  • Nonretentive subgroups
  • Primary failed to obtain initial bowel training
  • Toilet Fears Avoidance
  • Manipulative used by child to control the
    environment ODD??
  • Irritable Bowel Syndrome

38
EncopresisPrevalence
  • 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

39
EncopresisEtiology
  • 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

40
EncopresisEtiology
  • 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

41
EncopresisEtiology
  • 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

42
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

43
EncopresisTreatment
  • Not as well researched as enuresis
  • Intervention modalities
  • Education
  • Biofeedback
  • Behavioral
  • Medical

44
EncopresisTreatment
  • Medical and Educational approaches
  • Diet and exercise (e.g., high fiber diet, fluids)
  • Laxatives or enemas
  • Behavioral
  • Reinforcement, overcorrection, skill-building
    techniques
  • Biofeedback
  • Muscle strengthening/relaxing exercises

45
EncopresisTreatment
  • Schroeder Gordon (2003)
  • plumbing problem conceptualization
  • Education
  • Information about the GI tract and its
    functioning
  • Information about diet and exercise
  • Medical Interventions
  • Enema for impaction and laxatives

46
EncopresisTreatment
  • 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

47
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 OBrian 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)

48
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

49
Basics of Sleep - Stages
  • REM - Dreaming, brains active, body immobile
  • NREM - quiet, deep restorative stages
    associated with tissue growth/repair, hormones
    released for development

50
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/

51
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
52
BEARS AssessmentSimple 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)?

53
BEARS AssessmentSimple 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?

54
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

55
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)

56
Sleep Disturbances in ChildrenParasomnias
  • Disruptions during sleep or at the transition
    from sleep to wakefulness
  • Nightmares (REM), Very common
  • Sleep Bruxism, gt50 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

57
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

58
Sleep Disturbances in ChildrenObstructive 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

59
Sleep Disturbances in ChildrenNarcolepsy
  • 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

60
Sleep Disturbances in ChildrenPeriodic 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

61
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

62
Sleep Interventions
  • Medical and/or Behavioral
  • Medications
  • Tonsilectomy
  • Weight Loss
  • Sleep Hygiene

63
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.

64
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.

65
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.

66
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.

67
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.

68
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.

69
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.

70
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

71
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

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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

73
Typical Development of Eating Behaviors
  • 9-10 months drinks from cup with spout, brings
    spoon to mouth
  • 15 months self-feeding

74
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

75
Mealtime Rules
  • 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
  • Time out for rule breaking or disruptive behavior
  • (Christophersen Hall, 1978)

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Eating ProblemsPica
  • 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

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Pica
  • Etiology nutritional deficiencies, parental
    neglect, impoverished environment, lack of
    stimulation
  • Treatment
  • Parent education
  • Behavior therapy
  • Overcorrection
  • Rewarding other behaviors

78
Rumination
  • Intentional and repeated regurgitation of food
  • Not associated with a medical problem
  • This is developmentally appropriate in children lt
    6 months
  • Important to assess parent-child interactions

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Failure to Thrive
  • Childs weight falls below normal
  • gt2 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

80
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

81
Failure to Thrive
  • Infant risk factors
  • Prematurity
  • Difficult temperament
  • Depression
  • Physical Illness

82
Failure to Thrive
  • Environmental risk factors
  • Poor financial resources
  • Lack of social support
  • Poor-quality home environment
  • Being youngest in large family

83
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

84
  • Any
  • Questions?
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