Introduction to
Behavioral
Pediatrics
Jodi Polaha, Ph.D.
Assistant Professor, Pediatrics
Munroe-Meyer Institute
University of Nebraska Medical Center
Overview
Encopresis
 Enuresis
 An empirically-supported approach to
day time toilet training
 An empirically-supported approach to
night time toilet training

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
Encopresis
Medical Workup/Management
 Bowel habits assessment
 Education
 Diet assessment/Changes
 Compliance/Behavioral protocol

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

Encopresis
Medical Workup/Management
 Bowel habits assessment

Encopresis
Medical Workup/Management
 Education

Symptoms of constipation
 Functioning of bowel
 Behavioral “causes”
 Diet

Encopresis
Medical Workup/Management
 Education
 Diet assessment/Changes

Diet diary
 Behavioral protocol to increase fiber

• Premack principle
Encopresis
Medical Workup/Management
 Education
 Diet assessment/Changes
 Behavioral Protocol (to be discussed)

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

Enuresis
Primary vs. secondary
 Nocturnal vs. diurnal

Enuresis
Medical evaluation
 Assessment of compliance
 Behavioral protocol

First time toilet training
Among top concerns expressed by
mothers on internet, call-in services
 Most frustrating
 Lots of “lore”

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
Empirically supported toilet
training

Thinking time question #1a:

How could you provide a child with
lots of practice in toileting?
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?

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?

Empirically supported toilet
training

Toilet Training in a Day (Azrin & Foxx)

Repetition
• Fluid load
• Frequent toilet sits
• Pants checks
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
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
Empirically supported toilet
training
Institutionalized incontinent adults
 Typically developing children with
toileting resistance
 Mass audience of first-time learners

Empirically supported toilet
training

Thinking time question #2:

What if the child refuses to sit on the
toilet?
Encopresis

Thinking time question #3:

What would be a good behavioral
protocol for a child who is soiling daily
after school?
Enuresis

Thinking time question #4:

What would be a good behavioral
protocol for a child who is wetting daily
at daycare?
Empirically supported treatment
for nocturnal enuresis
Assessment
 Education
 Urine alarm
 Support to maintain integrity

Empirically supported treatment
for nocturnal enuresis
Assessment
 Education

Prevalence
 Medication vs. Urine alarm

Empirically supported treatment
for nocturnal enuresis
Assessment
 Education
 Urine alarm

Overlearning
 Dry-bed training
 Arousal Training

• Reward for waking to moisture alarm
Empirically supported treatment
for nocturnal enuresis
Assessment
 Education
 Urine alarm
 Support to maintain integrity

Nocturnal enuresis

Thinking time question #5: What if the
child won’t wake to the alarm?
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

Darren
Number of Wet Beds Per Week
16
14
12
Wet Beds Pre
Treatment
Wet Beds 1 DDAVP
10
8
6
Wet Beds 2 DDAVP
4
2
June
June
June
June
May
May
May
May
April
April
April
April
0
Darren
Number of Times Mom Intervened At
Night
16
14
12
10
Mom Pre Treatment
Mom with 1 DDAVP
Mom with 2 DDAVP
8
6
4
2
June
June
June
June
May
May
May
May
April
April
April
April
0
Darren: Treatment Plan
Sleep assessment: Rule out apnea
 Operant training: Wake to alarm
 Maintenance: Medication, no alarm

Darren: Treatment Plan

Arousal Training
Familiar, loud, clock-radio.
 Contingency for success.
 Two alarms per night.

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.
Darren
Number of Wet Beds Per Week
Ap
ril
Ap
ril
M
ay
M
ay
Ju
ne
Ju
ne
Ju
ly
Ju
l
Au y
gu
st
16
14
12
10
8
6
4
2
0
Pre Treatment
1 DDAVP
2 DDAVP
2 DDAVP + Alarm
Darren
Number of Times Mom Intervened At
Night
Ap
ril
Ap
ril
M
ay
M
ay
Ju
ne
Ju
ne
Ju
ly
Ju
l
Au y
gu
st
16
14
12
10
8
6
4
2
0
Pre Treatment
1 DDAVP
2 DDAVP
2 DDAVP + Alarm
Darren
Frequency of Self-Waking to Toilet
Ap
ril
Ap
ril
M
ay
M
ay
Ju
ne
Ju
ne
Ju
ly
Ju
l
Au y
gu
st
16
14
12
10
8
6
4
2
0
Pre Treatment
1 DDAVP
2 DDAVP
2 DDAVP and Alarm
Darren
Number of Wet Beds Per Week
Ap
ril
Ap
ril
M
ay
Ju
ne
Ju
ly
Ju
ly
Au
Se gus
t
pt
em
be
r
16
14
12
10
8
6
4
2
0
Pre Treatment
1 DDAVP
2 DDAVP
2 DDAVP + Alarm
2 DDAVP
Darren
Frequency of Self-Waking to Toilet
Ap
ril
Ap
ril
M
ay
Ju
ne
Ju
ly
Ju
l
Au y
Se gu
s
pt
em t
be
r
16
14
12
10
8
6
4
2
0
Pre Treatment
1 DDAVP
2 DDAVP
2 DDAVP and Alarm
2 DDAVP
Darren
Number of Wet Beds Per Week
Ap
ril
Ap
ril
M
ay
Ju
ne
Ju
ly
Ju
Au ly
Se gu
pt
s
em t
O ber
ct
ob
O er
ct
ob
er
16
14
12
10
8
6
4
2
0
Pre Treatment
1 DDAVP
2 DDAVP
2 DDAVP + Alarm
2 DDAVP
1 DDAP + Alarm
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.

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.