Elimination and sleeping issues

Question 1

Enuresis

Answer 1

• Enuresis is the repeated involuntary or intentional discharge of urine into bed or clothes beyond expected age
• According to the DSM-V Enuresis is diagnosed when happens beyond 5 years old, with a frequency of two times per week for at least three months
• Enuresis is classified as Primary and Secondary and as Nocturnal, Day time incontinence and mixed. Primary they had this all along, secondary this develops later after they have been fine for some time.

normal up to age 5 - often happens at school
Can occur due to trauma

Question 2

Developmental considerations Enuresis

Answer 2

• Age-appropriate challenge
• Communication skills - can they say ‘Mum I need to
  go to the toilet?
• Social and emotional development - can they tell when they need to go to the toilet?
• Cognitive skills - need to feel the need, recognise the need, plan going to the toilet.
• Motor skills- have to be able to hold it on the way to the
  toilet.

Question 3

Potential reasons

Answer 3

• Organic causes - Medical treatment
• Primary Enuresis - developmental delays, inefficient training. Primary usually happens because never had
  sufficient training. Often goes with neglect or
  permissive parents. If they didn’t have clear boundaries
  and they just hope child will grow out of it.
  Intellectual disability may play a part.
• Secondary Enuresis – personal or family changes, stressful situations or more complex situations. Secondary can be because of stressful situation
  or trauma can play a part. However, research says children who have eneuresis are likely to come
  from parents who also had eneuresis. Highly genetic.
  Also higher in boys than girls. Need a thorough interview with parents to determine cause.

Question 4

Consequences of enuresis

Answer 4

• Feelings of guilt
• Low self-esteem
• Aggression
• Depression
• Isolation

Often lots of shame - whole family might isolate, such as go on camping trips with other families. Family might not understand and become aggresive. In most cases they do grow out of it. But even then, we want the family to get support. Early intervention is key..

Question 5

Enuresis Assessment

Answer 5

• Medical assessments to rule out organic causes
• Family and developmental history
• Records
• Observation
• Teacher and parents report
• Interviews with other professionals or relevant people if appropriate - how did it start, - how do parents react? most common

Do they make the child wash their own sheets? Is this happening every lunch time? - Maybe child has no friends and accident is out of anxiety. from parents to monitor when it happens. Good to get info from paediatrician, and charts/diaries

Question 6

Enuresis Interventions:

Answer 6

• CBT
• Cognitive techniques - child makes statements and repeats them e.g. ‘when I need to go to the toilet I will wake myself up” Or visualisations - you’re in a movie. In the movie, you can picture needing to go, you can picture your character getting up and feeling how good it is to go etc.
• Urine alarm - Goes in underpants. If child is sleeping and starts to urinate, it wakes the child up and the child goes to the toilet. But it takes up to 12 weeks to work. Must therefore go with other therapies, eg, CBT. rewards, sticker system, leads to habit.
• Medication - usually last resort. Doesn’t allow child to produce urine. But if child has more water than normal they can get water intoxication.

Question 7

Encopresis

Answer 7

• Encopresis is the repeated passage of faeces, usually of normal or near-normal consistency in places not appropriate in the individuals’ own sociocultural settings. Can be present with or without constipation
• According to the DSM-V Encopresis is diagnosed in children of at least 4 years old with a minimum frequency of one episode per month

Boys 6 times more likely to develop than girls.

If this happens with constipation, in the rectum faeces are hard and then other soft faeces leak around the hard stool. Child cannot control this. May or may not occur with enuresis. When it isn’t related to constipation, more related to stress etc.

Question 8

Psychological Assessment encopresis

Answer 8

• Toilet training and stooling history
• Gather history, cognitive, behavioural, and contextual information to identify potential predisposing and perpetuating factors of encopresis
• Gain an understanding of family’s knowledge and familiarity with constipation and encopresis
• Assess current toileting-related skills
• Screen for psychological or behavioural comorbidities that may impact treatment
• Determine readiness for intervention

Question 9

Medical Assessment encopresis

Answer 9

• Gather stooling history and determine whether warning signals are present
• Determine the current stool burden and assess for need of clean out
• Assess previous medical interventions for constipation and encopresis
• Determine which medical intervention is most appropriate for presentation and patient specifics
• Refer for further medical evaluation if warning signs are present

Same as enuresis - want to have an interview with
parent. Parents usually like to sit in the middle of the
room with lots of different health professionals around so as not to repeat themselves. Also good to work with the child on self-esteem etc concurrently.

Question 10

Intentional encopresis

Answer 10

Usually cases where there are foster homes, inpatient
units. Have no control over anything, so they can control this. Some complex cases, will smear faeces on walls etc.
And in cases when child has trouble moving, and it is easier to just let go here than make the effort to go to the toilet.

Question 11

Behaviours to increase for encopresis

Answer 11

Sitting on the toilet when asked
Sitting on the toilet for a duration of time
Increasing awareness of and response to the urge to stool
Effective “pushing” when sitting on the toilet
Recognising a soil and getting cleaned up
Taking medications

Try strategies for 6-8 weeks at least. Parents are going to get upset if things don’t work straight away. Have to be humble, and say we wish there was a pill.

Question 12

Both enuresis and encopresis?

Answer 12

If they have both, they can be diagnosed with both. Not just put it down to encopresis with urine difficulties

Question 13

Sleep disorders normal development

Answer 13

Newborn -> Sleep around 16 hours per day, Recovery from the birth experience

Week six -> 15.5 hours per day Early rhythm of sleep
changes – babies are more alert and responsive. Around 30 % of babies will not achieve this rhythm.

Months four to six -> 14 hours. Sleeps through the night and achieve a predictable rhythm.

Look for things like autism. We are more equipped to detect it in babies these days.
Some cultures the children sleep with parents until 11 or 12, so we need to understand cultural differences. Can’t just say ‘don’t bring child to sleep with you’.

Question 14

Self-soothing sleep

Answer 14

Some self-soothe and go back to sleep, or they cry. Babies to self soothe, there needs to be regulation through co-regulation first. When children cry, they know their parent will soothe them. So next time they wake up, they have internalised that parents are there.

When children are playing and making noises, this is them self-soothing, practicing what they’ve heard from parents.

Question 15

Regulation and co-regulation sleep

Answer 15

• Interact in a warm and responsive manner
• Recognize children’s needs
• Hug and hold the child when is distressed
• Create a routine that can provide a stable and consistent environment
• Teach self-soothing strategies by modelling them
• Use age-appropriate positive behavior management strategies to promote rules
• Monitoring, and coaching of specific self-regulation skills such as identifying and expressing emotion, calming down, waiting, and solving problems

Interview parent on what they do when your baby
cries? How do you calm your baby?

Question 16

Attachment sleep

Answer 16

• Children with unreliable parents do not know if will or not receive attention -> Anxious - they just want parent to be there
• Secure – children know that their parents will address their needs
• Avoidant – Children show no distress with separation, I’ll just solve my needs here and not call parent.

Question 17

Avoidant attached children

Answer 17

Watch out when parent says ‘oh he’s great, he plays on his own.’ As fantastic as that sounds for mum, this is showing the absence of something. This becomes clear in session when they tackle a lot more. They’ve learnt that they can’t talk to mum. Teach mum to provide support even when he doesn’t ask. Then next session usually report, oh I helped and he it was great and he asked me to play the next day…

Question 18

Assessment and Intervention sleep

Answer 18

Assessments

• Comprehensive Interview
• Observations
• Developmental Assessment with a testing tool. For example: The Bayley Scales of Infant Development

Interventions

• Developmental guidance
• Regulation based approaches
• Psychotherapy approaches

Question 19

Obstructive Sleep Apnea

Answer 19

Snoring affects airways, affects sleep, affects partners. Insomnia can also be a consequence, headaches, fatigue etc as a result. Not fatal but can have an effect on health due to fatigue. Oxygen levels drop which can trigger chest pain.

• Irregular breathing
• Severe sleep deprivation
• Nocturia – excessive need to urinate during the night
• Loud snoring
• Devices such as Continuous Positive Airway Pressure (CPAP) have a high successful rate
• Surgery is recommended in some cases (more in children, adults surgery would be the last resort).

Question 20

Night terrors

Answer 20

• Children cry and scream after they fall asleep
• Each episode can last from five to 30 minutes
• It is not recommended to wake children up, because they are not aware of what’s happening, they’ll just go back to sleep.
• Children don’t remember the night terror episode
• Night terrors tend to disappear when reaching adolescence

Children get aggressive and parents get scared. If you wake them up they will be more disturbed. Psychoed best practice. As clinicians working with parents, they should follow a diary. Maybe child exercises more, have a lighter dinner etc. Not all parents have a bed routine. Not much we can do with child because they aren’t aware what’s happening.
Get paediatrician on board again, so they can assess for other things.

Question 21

Narcolepsy

Answer 21

Five key symptoms:
- Day sleepiness
- Cataplexy - the muscles become weak - emotions
influence movement. People diagnosed with type 1 narcolepsy experience episodes of cataplexy, while people with type 2 narcolepsy do not.

• Inability to move at the start or the end of sleep (sleep paralysis)
• Vivid hallucinations
• Fragmented sleep.

Question 22

Intellectual Disability trajectory

Answer 22

• Evidence from teachers, other professionals and family of the need to assess
• Interview
• Assessment - Individual Background, Academic Background, Family Background (parent might have it too, gone under the radar), observations
• Report
• Feedback session

Question 23

What you need for diagnosis of ID?

Answer 23

DSM-V
Department of Education
Multidisciplinary team

Question 24

ID reporting guide

Answer 24

Make sure it wont put child at risk. Be mindful about who has access to report. Make sure private info remains private. It should support diagnosis or be of benefit. if talking about sexual abuse, maybe leave that out if it will go public, just say ‘trauma’.

Think about:

• Who is going to read the report?
• What is the purpose of the assessment?
• Am I addressing the reason for referral?
• Am I integrating relevant information from the interview?
• How am I writing the diagnosis?
• Is my report friendly and accessible to everyone involved?
• Is my report integrating the reason for referral, the assessment results and writing appropriate recommendations?

Question 25

Feedback session for ID

Answer 25

When we finish the assessment, Make sure wherever the child goes the child receives support. Want to create safety net of support. If you only address teach or only mum, it won’t be consistent and maintainable.
Which recommendations worked, and which didn’t. Should we just monitor progress or keep intervening?

Question 26

Learning disabilities: Difficulties or Disabilities?

Answer 26

• Sensory impairment
• Challenging behaviour
• Emotional issues
• English as an additional language
• Ineffective instruction
• Socio-economic status
• Personal or family trauma
• Inadequate academic program

Possible a child doesn’t have a learning disability but does have difficulties brought about by trauma and low SES

Question 27

Learning Disabilities

Answer 27

• Learning disabilities have a lifelong impact
• Neurodevelopmental or genetic
• Intervention does not seem to work
• Children with learning disabilities do not have an intellectual disability, they could be very bright in fact.

Question 28

Specific Learning Disorders

Answer 28

These are dyslexia, dysgraphia and dyscalculia

Learning disabilities may produce lifelong impairments
What makes a difference is:
- Support
- Early intervention
- Strategies

Question 29

SLDs strategies

Answer 29

• Explicit
• Systematic
• Cumulative
• Based on strengths
• Constantly changing
• Creative and out of the ordinary

Give them the right tools -> because they can’t write, people focus on writing. You need to practice writing. Building on weakness might mean they don’t thrive on their strengths

Question 30

When to refer? SLD

Answer 30

Decision should be made based on the following criteria:

• Observations over a period of time*
• Data collected from work in class
• Identification of areas of concern
• Trial and error of few different strategies in the classroom
• Response to Intervention Model (RTI)

Question 31

Response to Intervention Model SLD

Answer 31

3 tiers of support.
Whole class intervention tier 1.
Then for those 5 children that didn’t understand, get a different way of teaching it tier 2.
Then out of the 5, there will be 1 or 2 who still need a different approach -> tier 3.
Can’t jump from tier 1 to 3.

Question 32

How can we help? psychs working with SLD

Answer 32

• Working together with a speech pathologist or/and a psychologist
• Keep close communication with parents
• Assistive Technology
• Take advantage of their strengths
• Set them to achieve
• Teach them rather than test them
• Acknowledge the negative effects that LD may have on their mental and physical health

assisted tech - write text and it anticipates what you want to wright. For children who can’t write, assisted tech allows you to focus on the info they have to convey, or classify or provide There are tonnes of apps for dysgraphia

Question 33

Communication Disorders

Answer 33

• Language Disorder
• Speech Sound Disorder
• Social (pragmatic) communication Disorder
• Childhood-onset fluency disorder (stuttering)

likely we ill be supporting a speech pathologist.
So we don’t need to know a whole lot.

Question 34

Language Disorder

Answer 34

Diagnostic Criteria

• Persistent difficulties in the acquisition and use of language across modalities – spoken, written, sign language – due to deficits in comprehension or production that include:
• Reduce vocabulary
• Limited sentence structure
• Impairments in discourse
• Language abilities are substantially and quantifiably below those expected for age with consequences in everyday activities
• Onset of symptoms is in the early developmental period
• The difficulties are not a consequence of hearing or other sensory impairments, motor dysfunction, or another medical or neurological condition and are not explained by ID or GDD

Question 35

Speech Sound Disorder

Answer 35

• Persistent difficulty with speech sound production that
  interferes with speech intelligibility or prevents verbal
  communication messages
• The disturbance causes limitations in effective
  communication that interfere with social participation,
  academic achievement, or occupational performance,
  individually or in any combination
• Onset of symptoms is in the early developmental
  period
• The difficulties are not attributable to congenital or
  acquired conditions such as cerebral palsy, cleft
  palate, deafness or hearing loss, traumatic brain injury,
  or other medical neurological condition

Question 36

Social (Pragmatic) Communication Disorder

Answer 36

A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by:
- Deficits in using communication for social purposes
- Impairment of the ability to change communication to
match the context or the needs of the listener
-Difficulties following rules for conversation and storytelling
- Difficulties understanding what is not explicitly stated and nonliteral or ambiguous meanings of language
B. The deficits result in functional limitations in effective
communication, social participation, social relationships,
academic achievement, or occupational performance,
individually or in combination
C. The onset of the symptoms is in the early developmental period
D. The symptoms are not attributable to medical or neurological condition, low grammar abilities, ASD, ID, GDD (GDD is global developmental delay - so profound
you can’t assess them) or another mental disorder

Question 37

Childhood-onset fluency disorder (stuttering)

Answer 37

A. Disturbances in the normal fluency and time patterning of speech that are inappropriate for the individual’s age
and language skills, persistent over time, and are
characterized by frequent and marked occurrences of
one or more of the following:
- Sound and syllable repetition
- Sound prolongations of consonants as well as vowels
- Broken words
- Audible or silent blocking
- Circumlocutions
- Words produced with excess of physical tension
- Monosyllabic whole-word repetitions

B. The disturbance causes anxiety aboutspeaking or limitations in effective
communication, social participation, academic or
occupational performance

C. The onset of symptoms is in the early
developmental period (Later-onset cases are
diagnosed as adult-onset fluency disorder)

D. The disturbance is not attributable to a
speech-motor or sensory deficit, dysfluency
associated with a neurological issue or another
medical condition or mental disorder

Question 38

Communication disorders Support

Answer 38

• Multidisciplinary team
• Medical and psychological assessments
• Include teachers and other educators
• Provide psychoeducation to parents

If the child is not doing what is expected the parent thinks they are doing something wrong. This is not the case, they just have to try more strategies