Toileting, Sleeping, and Eating:
Three Daily Common Problems
Rachel J. Valleley, Ph.D. & John Begeny,
M.S.
Munroe-Meyer Institute
University of Nebraska Medical Center
What does toileting, sleeping,
and eating have in common?
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Happen every day
Things kids don’t like to do
If not good at listening, often have
problems in one or more of these areas
Teaching Behavioral Skills
The Three Essentials:
1.
Predictability
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In your daily structure
In the consequences you provide
Teaching Behavioral Skills
The Three Essentials:
1.
Predictability


In your daily structure
In the consequences you provide
Practice
2.
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Break the new skill down to make it easy at first
Give lots of opportunities to try it (over and
over)
Provide predictable feedback for success vs.
failure
Teaching Behavioral Skills
The Three Essentials:
1.
Predictability


Practice
2.

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
3.
In your daily structure
In the consequences you provide
Break the new skill down to make it easy at first
Give lots of opportunities to try it (over and
over)
Provide predictable feedback for success vs.
failure
“Big Difference”
Teaching Behavioral Skills
Creating a “Big Difference”
Your consequence for demonstrating a
skill appropriately should be
VERY DIFFERENT
than your consequence for demonstrating
a problem behavior.
Prerequisite to toileting, sleeping,
and eating
Being a good
listener
Increasing Compliance
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1. Frequent, intermittent “bursts” of
attention for average and okay behavior
2. Build relationship by using Child’s
Game
3. Compliance Training
Teaching Behavioral Skills

The Child’s Game:
A relationship-building activity that makes
children want to earn your POSITIVE
attention.
Teaching Behavioral Skills
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DO
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Describe
Praise
Touch
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DON’T
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Command
Reprimand
Question
Compliance Training
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Effective Commands:
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Simple
Direct
One at a time
Start small
Compliance Training
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Give simple, practice command
Wait 5-10 seconds. If follows, praise/Big
Effect. If not, give time out warning if
does not comply. Wait 5-10 seconds. If
follows, praise/Big Effect. If not, put in
time out. After time out, repeat
command and procedure until
command is followed.
Time out

What is time out?
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Time out is the removal of attention,
tangibles, or anything interesting to the
child for a brief amount of time.
Misconceptions & mistakes:
Time out
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Not the chair
Have to sit quietly before time starts
1 minute per year
Think about what did wrong and feel
sorry
Talking to child in time out
Not expecting extinction burst
Decreasing the “No”
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How to do Time Out:
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Stop talking once told “Time Out”
Get to chair/spot with minimal guidance
Do not attend to anything in time out
Stay close enough to monitor but be aloof
Child serves 2-3 minutes
Let child out
Follow up with expecting appropriate
behavior
Addressing Toileting Problems
Readiness for toilet training
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Age: at least 20 months, preferably 2
years or older
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Physical readiness
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Most kids are ready by age 3, though
accidents commonly occur through age 5
Pick up toilet seat; lower/raise pants; walk
from room to room easily
Bladder readiness
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staying dry several hours at a time;
urinating 4-6 times/day and fully emptying
Readiness continued
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Language
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Instructional
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understands words like “wet,” “dry,”
“pants,” and “bathroom.”
Understands simple directions
Compliant with directions
Bladder and Bowel Awareness
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Look for signs, not just words (e.g., the
pee-pee dance)
Preliminary suggestions
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Let your child watch and explain in
simple words what you’re doing
Teach child to raise/lower pants
Make sure child can follow instructions
Set out a potty chair
Give a lot of praise for any type of
toileting behavior
Scenario 1: Toileting needs to
happen NOW
Steps for toilet training
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Increase fluid intake (1 cup of liquid/hour)
Frequent toilet sits (approximately 1 every
15-30 minutes).
Check for dry pants every 15-30 min. and
praise/reward for dryness (e.g., dot-to-dot)
Also reward for using toilet
Use positive practice procedures
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Practice going to toilet 10 times after each
accident
Rewarding Desired Behavior
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The effects of our actions determine
whether we will repeat them
Reward: toilet sits (and other toileting
behaviors), dry pants, using toilet
Use:
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praise
incentives
and/or other mediums: sticker charts,
Magic Circle charts, dot-to-dot charts
Other important points about
positive practice
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Remain calm and accept that accidents will occur
When finding wet pants, say in matter of fact tone
that the child must practice now
Before practicing, say that he/she will have to put
on dry pants. Otherwise, avoid talking.
Start at scene of accident then calmly take child
by hand and lead to bathroom. Then have child
lower pants, sit on toilet, get up, and pull up
pants. Return to same spot and repeat 9 times.
As always, praise for actually using toilet.
Scenario 2: You need to help
with the toilet training process
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In general, follow the rules of:
Consistency
 Repetition
 High Contrast
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Consistency:
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Repetition:
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Formal consequences reliably occur for a)
dry or soiled pants, b) BMs or urinating in
toilet
High fluid load
Pants checks with immediate feedback
Schedules toilet sits
High Contrast:
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Grab bag and/or enthusiastic praise for
successful sits, being dry, and voids in
toilet
Clean up and positive practice for accidents
Little attention for accidents
Scenario 3: Child with an
elimination disorder
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Types of disorders:
Enuresis
1.
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Encopresis
2.
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Diurnal
Nocturnal
Both
With constipation
Without constipation
Note: NOT thought to be caused by
sexual abuse
Diurnal Enuresis
What is it?
Individuals of at least 5 years of age who
urinate in clothing two times per week
for at least 3 months, or presence of
clinically significant distress or
impairment in social, academic, or other
important areas of functioning
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Diurnal Enuresis
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Prevalence: approximately 0.5% to 2%
of 6 and 7-year-old girls and boys
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Much less common than nocturnal enuresis
Comprehensive assessment is important
General treatment approaches
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Medically based
Treat noncompliance??
Increase awareness of full bladder
Reinforcement program
Encopresis with constipation
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Individuals who are at least 4 years old
who pass feces into inappropriate
places (e.g., clothing, floor) at least
once per month for at least 3 months
Can be voluntary or involuntary, but is
not due to medications or other
substances
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Over 90% is involuntary and due to
constipation
Encopresis facts
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Approximately 1 to 5% of pediatric
patients
Primary cause is fecal retention, which
in the large majority of cases is beyond
the child’s immediate control
Treatment of retentive
encopresis
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Education and demystification
Clean out the system (e.g., enemas and/or
laxatives)
Scheduled toilet sits
Reward toilet sits, BMs after scheduled
sits, and self-initiated BMs
Increase fiber, fluids, activity level
Possibly use stool softener
Ensure child’s feet are on flat surface when
toileting
Treatment of encopresis
(continued)
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Data collection
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When do they go?
Do they go frequent enough?
Is treatment effective?
Can we decrease meds?
Solving Sleep Problems
Common Sleep Problems
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DSM-IV Types
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Insomnia/Hypersomnia
Nightmare Disorder
Sleep Terror Disorder
Sleepwalking Disorder
Sleep Problems
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Most common: Bedtime resistance
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Morning wake-up problems
Sleep-onset delays up to 1 hour
Night awakening
Sleep Problems
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Most common: Bedtime resistance
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Sleeping independently is a skill
Laying in bed is “time-out”
Sleep Problems
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What could increase consistency?
What could provide repetition?
How could high contrast be used?
Sleep Problems
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Bedtime resistance
1.
2.
3.
4.
5.
6.
7.
8.
Assess overall noncompliance.
Take data.
Address consistency of pre-bed routine.
Move bedtime closer to sleep onset.
Set “sleep window.”
Use some ignoring procedure.
Use some sort of reinforcement for sleep.
Extend sleep window.
Naps: Steps to good sleep
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Demonstrate sleep compatible behavior
Prompt sleep compatible behavior
Praise sleep compatible behavior
FREQUENTLY at first
Use stickers for sleep compatible behavior
Offer incentive to follow nap if quiet during
naptime
Use a time out if absolutely necessary
Common Objections to Using
Tangible Rewards
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Rewarding children for good behavior is
bribery
Shouldn’t reward children for what they
should already do
Expect rewards for everything
Preference Assessments
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Before developing any incentive
program, determine what the child likes
by
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Watching what they chose when many
options available or over time
Pair objects together and ask which they
prefer
Have child make a list of reinforcers
Grab Bags: Creating Effect
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Write down list of “reinforcers” on index
card
Place in box/bag
Meets specified goal = reward card
“Reinforcer” Menus: Option 1
Okay Sticker, Sucker,
(1-3) Read book
Good Pencils, Rent
(4-6) video, Go to DQ
Great Go to movie,
(7+) Have friend
over, Stay up
late
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Set criteria for each
level of behavior
Select “reinforcers”
for each level
“Reinforcers” should
be of more value to
child with each level
“Reinforcer” Menus: Option 2
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Each day give 3-5 options from big list of
“reinforcers” that the child can pick from and
earn that day if criteria met
Rewards Available
Today
Go to Park, 30 minutes
computer, Play Monopoly
Dot-to-dots
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As child engages in sleep compatible
behavior, they earn a line on chart and
is praised as behavior occurs
When completed dot-to-dot, earns
reward
Would want to initially have earn lines
after few seconds of sleep compatible
behavior and slowly increase time
between bursts of attention
Magic Circle Charts
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Each time child is quiet during nap,
earns a star/sticker on chart and is
praised as behavior occurs
When lands on “magic circle”, child
earns incentive
Best to use after dot-to-dot and child is
more consistently quiet during nap
Solving Meal Problems
Types of feeding disorders
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Content of food
Quantity of food
Method of eating
Most likely to see food refusal: “The
Picky Eater”
Mealtime Behavior Problems:
How to solve “The Picky Eater”
Problem
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What could increase consistency?
What could provide repetition?
How could high contrast be used?