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

Retention Control Training:

Rewarding child for increasing periods of
urine retention over 2 week period
Supportive approaches:
Education
Fluid restriction
Night Awakening
Case: 3-year-old is experiencing difficulty with toilet-
training for bowel and bladder.
Behavioral program for intensive daytime toilet training

A. 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.

B. Have XXX sit on the toilet for 5 minutes every half hour.
If she urinates (even a little bit) or moves his/her bowels:
1) Give lots of praise and applause!!!
2) Give candy immediately (keep candy in the bathroom so it can
be given quickly)
3) 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).
C. If she has an accident... do Positive Practice
1) Physically guide her to the bathroom
2) Give reminder in a neutral voice: "wet pants are bad or
oops, youre wet (avoid further conversation)
3) Guide her to pull down pants
4) Guide her to sit on the toilet (just sit for a couple seconds)
5) Guide her to stand and pull pants up
6) 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.

D. 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

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 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: 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
 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?
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
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
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 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 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

Learning disabilities
Lower intelligence
Poor school achievement
Higher rates in ADHD compared to non-
ADHD
 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
 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
 Assessment of Enuresis
Date Bedtime Time of Time of Size Parent
Wakening wetting Behavior
 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
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 Enuresis
Establish good toileting habits
1. Stop using diapers (exceptions)
2. Recording times child typically goes (every 30
minutes)
Child must show regular pattern with intervals
3. Regular sitting Positive practice
5 minutes at regular times
Make this a positive experience
Use rewards for sitting or toileting
 Treatment:
Daytime/Mixed Enuresis

4. Cleanliness training
Matter-of-fact
Cleaning themselves, clothes, floor if wet
Sitting on toilet for 5 minutes after each wet
5. Charting progress and providing rewards
6. Urine alarm clock
Reminder/cue
Increase awareness
 Treatment:
Daytime/Mixed Enuresis
7. 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)
8. Once continence established
Over-learning increasing fluids
Fade positive reinforcement schedule
If nocturnal bedwetting: treat with urine alarm programs
9. Other tips:
Diet and exercise
Wait until child is ready
Nocturnal Enuresis Interventions
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1. Do nothing: Spontaneous Remission

2. Urine Alarm/Sleep Conditioning
3. Medication
 Comparison of Treatment Modalities for Nocturnal Enuresis
C. Carolyn Thiedke, M.D.
American Academy of Family Physicians

Cost for brand

name product
Treatment Advantage Disadvantage (generic)*
Bed-wetting Effective, low Takes weeks for $50 to $75, plus
shipping and handling
alarm relapse rate results; can be charges
disruptive to family
Desmopressin Rapidly High-relapse rate with 5-ml nasal spray: $149
for 5-mL bottle
(DDAVP) effective, few discontinuation 0.1-mg tablets: $72 for
side effects 30 tablets
0.2-mg tablets: $85 for
30 tablets

Imipramine Inexpensive, High-relapse rate with 25-mg tablets: $28 (8)

for 30 tablets
(Tofranil) works quickly discontinuation; side
effects, including
cardiotoxicity at high
doses
 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
Wet-Stop Child Bedwetting Alarm
 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 Enuresis

Bell and pad

Average use is 6 months
Increased success through:
overlearning
Use of parental reinforcement
Continuing to use the alarm intermittently
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:

1. Bell and pad or Wet Stops
2. 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.
3. 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).
First Night and Second Nights
1. set up the bell and pad according to instructions
2. before your child goes to bed, have him/her drink extra fluid
3. keep yourself within ear shot of the alarm
4. 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."
5. 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).
6. have your child practice lying in the bed, getting up to go to the
bathroom several times in a row.
7. encourage your child to drink more fluid before going back to
sleep

Third Night through 2nd week

1. all steps above are in place EXCEPT do not encourage
additional fluids.
2. provide your child with rewards for each dry morning
3. your therapist will help you establish when to fade out the use of
the bell and pad.
After 14 Consecutive Dry Nights: Overlearning
1. Child drinks 6-8 ounces of favorite liquid (non-caffeinated)
before bedtime
2. Some accidents are expected
3. Continue until 14 more consecutive dry nights

Intermittent Schedule
1. Tell your child that on some nights the parents will disconnect
the alarm after he/she has gone to sleep
2. Since they will not know when it is connected, this will help
him/her to learn to sleep through the night without the alarm
3. 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

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

Nonretentive subgroups
1. Primary: failed to obtain initial bowel
training
2. Toilet Fears: Avoidance
3. Manipulative: used by child to control
the environment ODD??
4. Irritable Bowel Syndrome
 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

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:
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:
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

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

Not as well researched as enuresis

Intervention modalities:
Education
Biofeedback
Behavioral
Medical
 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:
Treatment

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

Younger children have somewhat different patterns of

sleep than adults, but typically develop a normal adult
cycle by 8 years
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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
 BEARS Assessment
Simple 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 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 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 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
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 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

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 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

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 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

Medical and/or Behavioral

Medications
Tonsilectomy
Weight Loss
Sleep Hygiene
 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 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 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 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 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 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 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 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 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

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 Behaviors

9-10 months: drinks from cup with

spout, brings spoon to mouth
15 months: self-feeding
 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
1. Remain seated
2. Chew and swallow with mouth closed
3. Use utensils
4. Include children in conversation
5. Reward appropriate behavior
6. Remove food at end of meal
7. Allow snacks only if food was consumed
during meal
8. Time out for rule breaking or disruptive
behavior
(Christophersen & Hall, 1978)
 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
 Pica

Etiology: nutritional deficiencies,

parental neglect, impoverished
environment, lack of stimulation
Treatment:
Parent education
Behavior therapy
Overcorrection
Rewarding other behaviors
 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
Childs 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
 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
 Failure to Thrive

Infant risk factors:

Prematurity
Difficult temperament
Depression
Physical Illness
 Failure to Thrive

Environmental risk factors

Poor financial resources
Lack of social support
Poor-quality home environment
Being youngest in large family
 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
 Any
Questions?