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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

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common childhood problems

Common Childhood Problems

Psy 4930

September 12, 2006

common childhood problems2
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
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 training4
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 training5
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
treatment options
Treatment Options
  • Retention Control Training:
    • Rewarding child for increasing periods of urine retention over 2 week period
  • Supportive approaches:
    • Education
    • Fluid restriction
    • Night Awakening
slide7

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).
slide8
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, you’re 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 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
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 center10
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
  • 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
enuresis12
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
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
enuresis other factors
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
etiology of enuresis
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
etiology of enuresis16
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)
etiology of enuresis17
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
Risk Factors Enuresis
  • Learning disabilities
  • Lower intelligence
  • Poor school achievement
  • Higher rates in ADHD compared to non-ADHD
assessment of enuresis
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 enuresis20
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
treatment spontaneous remission
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
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
treatment daytime mixed enuresis24
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
treatment daytime mixed enuresis25
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
treatment daytime mixed enuresis26
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
nocturnal enuresis interventions http www kidney org news newsroom psa cfm
Nocturnal Enuresis Interventionshttp://www.kidney.org/news/newsroom/psa.cfm
  • Do nothing: Spontaneous Remission
  • Urine Alarm/Sleep Conditioning
  • Medication
slide28

Comparison of Treatment Modalities for Nocturnal Enuresis

C. Carolyn Thiedke, M.D.

American Academy of Family Physicians

treatment nocturnal enuresis
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
Urine Alarm

Wet-Stop Child Bedwetting Alarm

urine alarm31
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

treatment nocturnal enuresis32
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
slide33
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).
slide34
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.
slide35
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

encopresis definition and dsm criteria
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)
encropresis
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
encopresis prevalence
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
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 etiology40
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 etiology41
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
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
Encopresis:Treatment
  • Not as well researched as enuresis
  • Intervention modalities:
    • Education
    • Biofeedback
    • Behavioral
    • Medical
encopresis treatment44
Encopresis:Treatment
  • 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
encopresis treatment45
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 treatment46
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
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
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
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
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/
bears assessment simple set of sleep questions for parents
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)?
bears assessment simple set of sleep questions for parents53
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?
common sleep disturbances in children
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 children55
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
Sleep Disturbances in ChildrenParasomnias
  • Disruptions during sleep or at the transition from sleep to wakefulness
    • 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 children57
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
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
sleep disturbances in children narcolepsy
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
sleep disturbances in children periodic limb movement disorder restless leg syndrome
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
sleep disturbances in children61
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
Sleep Interventions
  • Medical and/or Behavioral
    • Medications
    • Tonsilectomy
    • Weight Loss
    • Sleep Hygiene
sleep hygiene recommendations used for 2 3 year old
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 old64
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 old65
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 old66
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 old67
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 old68
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 old69
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 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 difficulties71
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
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 behaviors73
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
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
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)

eating problems pica
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
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Pica
  • Etiology: nutritional deficiencies, parental neglect, impoverished environment, lack of stimulation
  • Treatment:
    • Parent education
    • Behavior therapy
      • Overcorrection
      • Rewarding other behaviors
rumination
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
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
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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
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Failure to Thrive
  • Infant risk factors:
    • Prematurity
    • Difficult temperament
    • Depression
    • Physical Illness
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Failure to Thrive
  • Environmental risk factors
    • Poor financial resources
    • Lack of social support
    • Poor-quality home environment
    • Being youngest in large family
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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
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Any

Questions?