Tag: Child Behaviour

Enconpresis in school aged children

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Posted on by Leonardo Rocker (Quirky Kid Staff)

Understanding and Managing Encopresis in Children

 

Encopresis (or faecal soiling) is one of the most frustrating difficulties of middle childhood, affecting approximately 1.5% of young school children (von Gontard, 2013). It is a debilitating condition to deal with as a parent, as it usually occurs at a stage when children are past the age of toilet training.

Encopresis is a common complaint amongst parents who visit the Quirky Kid Clinic as it often occurs in the context of other behavioural issues such as oppositional defiant disorder (ODD) or separation anxiety.

According to the Diagnostic Statistical Manual (DSM-V) (American Psychiatric Association, 2013) encopresis (or otherwise known as Elimination Disorder) is essentially the repeated passing of stools into inappropriate places, after the age at which toilet training is expected to be accomplished. In order to receive this diagnosis, 4 features should be present:

  • Patients chronological age must be at least 4 years
  • A repeated passage of feces into inappropriate places, which is either intentional or involuntary.
  • At least one such event must occur every month for at least 3 months.
  • The behaviour is not attributed to the effects of substances (e.g., laxative) or any other medical condition.

There are two basic categories of encopresis i) primary encopresis-which refers to children who have never attained bowel control, ii) secondary encopresis-which refers to soiling after successfully attaining toilet control usually brought upon by entering a stressful environment (such as family conflict).

What causes encopresis?

Parents of children with encopresis often feel frustrated as they often believe that their children play an active role in controlling their bowel movements.  While in some cases, soiling may be intentional, in other cases it may be involuntary and beyond the child’s control. It is important to be aware of the many possible causes for this disorder.

  • Biological factors: Functional constipation (persistent constipation with incomplete defecation without evidence of a structural or biochemical explanation) is one of the main causes of encopresis, accounting for 90% of cases amongst children (Har & Croffle, 2010). Children may withhold stools often because he/she is constipated and therefore experiences pain when there is a bowel movement. Chronic withholding of bowel movements causes children to lose the ability to defecate normally, and causes partial bowel movements of which children are often unaware. Other medical causes such as spinal cord damage, celiac disease or damage to the bowel can result in encopresis. Medications may also lead to non-retentive fecal soiling. Tricyclic anti-depressants, narcotics, and iron are likely to cause constipation that is severe enough to lead to encopresis and laxative abuse can cause severe diarrhea and fecal incontinence.
  • Psychological factors: Overall 30-50% of children with encopresis have a comorbid emotional or behavioural disorder (von Gontard, 2012).  In a large population study, school aged children with encopresis had significantly increased rates of separation anxiety (4.3%), specific phobias (4.3%), generalized anxiety (3.4%), ADHD (9.2%) and oppositional defiant disorder (11.9%) (Joinson et al., 2006). Children who present with Oppositional Defiant Disorder or Conduct Disorder (that is, children who are intentionally defiant and non-compliant to their parents or caregivers) may use inappropriate soiling as a form of retaliation, as a means to communicate their anger, or as an attention seeking strategy. There is also evidence to suggest that children who have encopresis experience higher levels of  anxiety and depression as a result, and these symptoms can exacerbate the symptoms of encopresis. A population study by Cox et al., (2002) found that children with encopresis had more anxiety and depression symptoms, exceeding the clinical threshold by 20% compared to control children.
  • Family and social factors: Children may develop delays in toileting due to unsuccessful toilet training as a toddler and intrusive toilet training. It may have been that children recieved discipline for having accidents or have been encouraged into toilet training before they were ready. Negative toilet training practice can cause children to associate using the toilet with punishment. In other cases, encopresis occurs when there is a stressful family situation such as divorce, birth of a sibling or transition to a new school. In severe cases, frequent soiling may occur in a child who has had a traumatic or frightening experience such as a sexual or physical molestation.

What are the potential risk factors for Encopresis?

In western cultures, bowel control is established in 95% of children by age 4 in 99 % of children aged 5 (von Gontard, 2013). Around primary school age (10-12 years old) 1.5% of children develop encopresis. Although every case is different, studies have shown that there are a number of risk factors, which are associated with the development of encopresis including:

  • Gender: encopresis is five times more common in boys than girls.
  • Abuse and/or neglect.
  • Inadequate water intake.
  • Presence of chaos or unpredictability in a child’s life.
  • Lack of physical exercise or a diet that is rich is fat/ sugar.
  • Presence of neurological impairment such as brain damage, autism, developmental delay and intellectual disability.
  • History of constipation or defecation.

What is the impact of encopresis in school aged children?

Encopresis can have a severe effect on the child, family and school environment. Encopresis is often a family preoccupation, as parents and siblings become increasingly frustrated as family activities may be disrupted due to the constant soiling. The family is left fruitlessly battling over the child’s bowel control, and the conflicts may extend to other areas of the child’s life such as school functioning and social circles such as friends. When the child becomes increasingly aware of these difficulties, they may become angry, withdrawn, anxious and depressed and may be a victim of bullying if other peers become aware. Studies have shown that encopresis children experience a greater amount of anxiety and depression symptoms, difficulties with attention, more social problems, disruptive behaviours and lower levels of academic performance (Mosca & Schatz, 2014).

What are the treatment options for encopresis in school aged children?

While encopresis is a chronic and complex problem amongst many families, it is treatable. As a parent, it is important to be aware that there is no quick fix for encopresis, the process might take months and relapse is very common. Sixty-five percent of patients are almost completely cured in 6-months and 30% show improvement (Har & Coffle, 2010).  The majority of children with encopresis can be effectively treated with a combination of medical, psychological and dietary interventions.

  1. Medical treatments: The first step to treating encopresis is to identify the cause behind the condition and seek medical advice from a pediatrician or GP. Medical examinations are important in order to rule out the existence of organic causes. Initially a doctor may prescribe a laxative to ease the passage of the hardened stool through the rectum. Once the stool has passed, substances such as fiber, enemas or laxatives may be used to empty the colon and decrease painful bowel movements.
  2. Behavioural modification with the assistance of a Psychologist is an integral treatment component for encopresis . In order for this to be effective, family tension regarding the symptom should be reduced and a non-punitive atmosphere should be established. Parents should encourage their child to sit on the toilet for 10 minutes after meals 2-3 times a day. The initial aim is to produce a bowel movement by giving the child the chance to get used to using the toilet and to be in tune with bodily cues.  Parents can create a reward system, which provides incentives for the child to use the toilet. He/she may receive a star or sticker on a chart for each day he/she successfully goes to the toilet without soiling and a special reward could be earned after an 80% success rate during the week. A recent meta-analysis by Freeman, Riley, Duke & Fu (2014) found that behavioural intervention is the most effective treatment for encopresis.
  3. Treat other co-morbidities: Comorbid emotional and behavioural disorders should be treated separately according to evidence based recommendations (von Gontard, 2013). If your child is presenting with anxiety, depression, or oppositional defiant disorder, these associated co-morbidities should be treated concurrently to reduce symptoms of encopresis. Untreated co-morbid disorders will reduce adherence and compliance and the outcome of encopresis treatment will not be optimal.

Other tips include:

  • Never tease or embarrass your child and do not show anger. Supporting your child’s self-esteem is essential. Name calling and teasing are frequent results when a child soils at school/and/or smells of feces so it is important that their self esteem is not affected as a result. While it may seem like purposeful behaviour at times, it may not be within your child’s control (as in the case of functional encopresis).
  • Encourage your child to drink lots of water, eat fiber rich foods such as fruits, vegetables and whole grains
  • Consider scheduling evidence based psychological intervention if your child feels shame, guilt, depression or low self esteem related to encopresis.
  • If your child shows no improvement after 6 months they should be referred to a gastroenterologist for additional assessment.

References:

American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Cox, D., Morris, J., Borowitz,S., & Sutphen, J. (2002). Psychological differences between children with and without chronic encopresis. Journal of Pediatric Psychology, 27,7, 585-591.

Freeman,K.A., Riley, A., Duke,D.C., & Fu, R. (2014). Systematic review and meta-analysis of behavioural interventions for fecal incontinence and constipation. Journal of Pediatric Psychology. 39, 8, 887-902.

Har, A.F., & Croffle, J.M. (2010). Encopresis. Paediatrics in review. 31,9,368-3754.

Joinson, C., Heron, J., Butler, U., et al. (2006). Psychological differences between children with and without soiling problems. Pediatrics, 117, 1575-1584.

Mosca, N., & Schatz, M. (2014). Encopresis: Not just an accident. NASN School Nurse. 28,5,218-221.

U.S. National Library of Medicine, MedlinePlus (2012). Encoporesis. nlm.nih.gov. Retrieved 12 September 2014 fromhttp://www.nlm.nih.gov/medlineplus/ency/article/001570.htm

von Gontard A.(2012). Encopresis. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva:

von Gontard, A. (2013). The impact of the DSM-5 and guidelines for assessment and treatment of elimination disorders. Eur Child Psychiatry, 22,61-67.

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Obsessive Compulsive Disorder in Children

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Posted on by Leonardo Rocker (Quirky Kid Staff)

Managing Obsessive Compulsive Disorder in Children

Regularly checking if the stove is turned off before leaving home or pressing the car alarm button two or three times just to make sure it is turned on are some of the behaviours most people  may display as part of everyday life. People with Obsessive Compulsive Disorder, however, experience these types of behaviours and associated obsessive thoughts persistently and frequently. As a result,  their day to day functioning is impaired and significant distress is caused.

Until recently, OCD was classified as an anxiety disorder due to the large role that anxious thoughts, feelings and behaviours can play. With growing research, OCD now stands alone as a diagnosis and related disorders such as hoarding and trichotillomania (hair pulling) are becoming increasingly recognised. OCD is characterised by obsessive thoughts such as contamination (germs), harm to self or others, symmetry, religion or sexual themes as well as compulsions such as excessive hand washing, checking, counting or praying. In OCD one or both of these will be present and will manifest in a cycle of symptoms. For example, thoughts about the house burning down (obsession) leads to anxiety which may be relieved by checking the stove repeatedly (compulsion). While completing a compulsion can lead some individuals to experience relief, this feeds into the unhelpful thinking pattern around the likelihood of the house burning down and thus increases the likelihood that the compulsion will be completed again and again. These thoughts and behaviours usually need to take up at least one hour per day before a diagnosis will be made.

Children can also suffer from OCD, in fact, most cases are diagnosed between the ages of seven and twelve. As with adults, the presence of some obsessions and compulsions are a typical part of development, however, for some children these can take over their life. About 0.2 – 1% of children will have OCD and about 3% of adolescents. A diagnosis of OCD will usually be considered if the thoughts and behaviours associated with the disorder continue for a long period of time, particularly if children do not seem to be deterred by the consequences of the compulsions such as getting in trouble. These children often tend to believe that performing a compulsion (e.g. excessively washing hands) will prevent a feared outcome (e.g. going to hospital). This is made more complicated by the fact that children generally have trouble distinguishing between healthy thoughts and behaviours and symptoms of OCD. When they do feel that something is wrong they are often too ashamed to tell an adult. For this reason we need to be aware of the warning signs and guide children through the recovery process. If concerned, you should always consult with a health professional like a Quirky Kid Psychologist.

Parents and other caregivers can look for signs that obsessions and compulsions are present. These signs will vary in different children and it is also important to be mindful that these experiences may occur for a number of reasons not related to OCD. They may include:

  • Reported or observed feelings of ‘stress’
  • Sleep deprivation
  • Depression and/or feelings of shame
  • Agitation
  • Slowness in performing tasks (e.g. getting dressed)
  • Seeming ‘manic’ or needing to be kept busy
  • Decline in academic performance
  • Angry outburst or challenging behaviour
  • Avoiding social situations
  • Family conflict over small things like setting the table

By being mindful of these signs and talking to your child you can determine if help is needed. A psychologist experienced in both child development and behavioural therapy will be most helpful and a psychiatrist can assist in deciding whether or not medication is appropriate and necessary. OCD is usually treated using Exposure and Response Prevention or ERP which involves exposing the individual to their feared situation (e.g. touching a garbage bin) and prevents them from completing their compulsion (e.g. washing hands). This allows them to learn to ‘sit with’ feelings of anxiety and change patterns of thinking which tend to overestimate the likelihood or severity of feared outcomes (e.g. getting sick). Just talking about the problem is usually not helpful and ERP is a highly effective form of therapy for OCD. Of course, this is best performed under the direction of a qualified professional.

OCD can put a strain on families and take the fun out of life for children who are affected so it is important to know how to help your child while also making sure that you have support for yourself. Although the behaviours can be difficult to deal with, children are not trying to misbehave or be annoying; they can’t help the way they are behaving and need support. On the other hand it is important not to participate in the rituals, for example, by constantly offering reassurance. Instead it is best to help your child to learn how to stop these rituals with the support of a professional. Also, many children find it helpful to externalise the symptoms or disorder of OCD by giving it a nasty nickname and treating it as something outside of them. They can then “boss back” the OCD and take charge of not letting the symptoms rule their life. Overall, it will be important to stick to family routines, avoid laying blame and be supportive of your child. Ensure that you have a support network in place for yourself and your family and that you are taking steps to manage your own stress levels while dealing with this challenge.

Recommended Resources:

Need help:
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References

OCD in Kids. Centre for Emotional Health, Macquarie University (website)

Wilensky, A. (2006). When Your Child has Obsessive – Compulsive Disorder. PsychCentral (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association.

Obsessive Compulsive Disorder. Australian Psychological Society (website)

Walitza, S., et. al. (2010) Genetics of Early-Onset Obsessive-Compulsive Disorder. European Journal of Child and Adolescent Psychiatry, 19 (227-235)

Ornstein, T. J., et. al. (2010) Neuropsychological Performance in Childhood OCD: A preliminary study. Depression and Anxiety, 27 (372 – 380)

Ivarsson, T. & Larsson, B. (2009) Sleep Problems as Reported by Parents in Swedish Children and Adolescents with Obsessive – Compulsive Disorder (OCD), Child Psychiatric Outpatients and School Children. Informa Healthcare UK ltd. DOI: 10.3109/08039480903075200

Calvo, R. et. al. (2007) Parental Psychopathology in Child and Adolescent Obsessive-Compulsive Disorder. Society of Psychiatry and Psychiatric Epidemiology, 42 (647 – 655).

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Managing Difficult Behaviour

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Posted on by Leonardo Rocker (Quirky Kid Staff)

Children are more likely to behave the way we would like them to when we create an environment that reduces opportunities for challenging behaviour. This means an environment that is rich in age appropriate, stimulating experiences but also one that minimises “triggers” for challenging behaviours like tantrums, aggression and defiance. The most important part of a child’s environment are the relationships that inhabit it. Relationships that are built on warmth and mutual respect will teach children prosocial behaviour and encourage them to live up to our expectations. Prevention is better than cure so with a few measures in place; an environment can be created in which behavioural challenges are less likely to arise, and we can be better prepared to respond when they do. So how do we create this environment?

Below are tried and tested suggestions we provide parent that visit us at The Quirky Kid Clinic.

Set clear rules and boundaries

Rules that are clear, reasonable and meaningful, help children to understand what is expected of them and provide you with simple reminders that you can give to children before situations get out of hand. Afterall, how can we expect them to behave in a certain way if we haven’t told them what that is? Only a few rules are needed and ideally, children will be involved in creating these as part of a team effort. You may even like to write up a family contract to sign and display somewhere in the house, (make sure the grown-ups sign too)! Keep the language positive and make it a project that everyone wants to be a part of.

Children are more likely to follow a rule if they feel an agreement has been met rather than that they have had something imposed upon them. Also, decide and make clear what the consequences will be for breaking the rules and always remember to follow through. Logical consequences like removing a toddler from the sand pit when they are throwing sand at their sibling work best for younger children and time-out can be helpful from about three years if used appropriately (e.g. one minute per year of the child’s age and minimal interaction so that the situation can defuse). Withdrawal of privileges such as loss of Gadgets time is only effective once the child is old enough to link their behaviour to a consequence that occurs later in time (about six years and up).

To be meaningful for children, consequences need to be immediate. It is most important that when enacting rules and boundaries parents are predictable and consistent. Studies have shown that children can sense when one parent has a different parenting style to another and this can lead to an increase in behavioural and emotional concerns.

Teach and support communication

Behaviour is communication. Usually, children behave in a certain way to tell us something and achieve a certain goal. They haven’t learnt the communication skills to tell us what is bothering them or what they need, and so they show us through their behaviour. As long as the message is getting across and their needs are being met the behaviour will continue. Look for what the message is behind the behaviour and help children to build their emotional language “I can see you are very angry!” Give them an alternative, more appropriate, ways to communicate as you support them in navigating the purpose behind their behaviour. This may be through the use of visual prompts or teaching and practising specific skills such as asking for help with a difficult task that would normally lead to frustrated outbursts. This goes both ways; it is important not to assume that communicating verbally is enough to tell a child what they need to know. Timers, visual schedules and stop signs are great tools for this. Quirky Kid has developed a tool called Tickets, to assist parents to do just this. It is popular and worth a try.

Provide Emotional outlets & Play!

Give children a chance to let it all ‘hang out!’ Children get stressed, anxious and frustrated just as we do so plenty of opportunities to express this in a safe and appropriate way will decrease the chance of these emotions bubbling over. Put on some music, paint, draw, dance and sing. Stomp around like angry monsters or just go for a run outside. Play is also an important way for children to learn emotional regulation, problem-solving and social skills. Take the opportunity to play with your child and hand over the controls. Giving them a chance to lead you in their choice of games is an excellent way to give children the sense of control that they often seek.

Catch them getting it right

Children seek out both positive and negative attention and can draw their parents in by doing the wrong thing. Be mindful of this and avoid giving attention to this kind of behaviour, consider giving yourself a time out if you need to. Save your attention for the behaviours you would like to see more of.

We almost certainly will tell a child when they are doing the wrong thing, but what about when they get it right? Plenty of specific, meaningful praise will remind children of the kind of behaviour you like to see and will encourage them to continue in the same way. Tell them exactly what would like to see more of, e.g.

“I really love the way you took your plate to the dishwasher before I had to ask, thank you!”

or

“That was such a kind thing to say to your sister, you have been playing together really nicely today.”

Reward schemes can also be helpful when you are trying to target a specific behaviour. Agree with your child on a reward that is meaningful to them and remember to reward but never bribe! As with consequences for challenging behaviour, rewards should be immediate. Also, they should not be taken away once they have been earned. Again, Quirky Kid has developed a tool called Tickets, to assist parents to do just this.

Know yourself and your triggers

Tired? Stressed? Had a bad day? Be mindful of how this can affect the way you respond to your child’s behaviour. Think about  what your buttons are and how you can respond with a level head when they are pushed. If you feel yourself being drawn into an argument, take a step back and try not to react in an emotional way as this usually adds fuel to the fire. Having some pre-planned strategies of how you will respond when certain behaviours occur will help you to feel calm and in control.

Finally, remember to look after yourself! Talk about that enormous tantrum and how it made you feel with someone you trust. Laugh about it, cry about it and take the time to refill your cup by doing the things you love. Think of the team of adults you have around you; consistency across parents and other caregivers will help support you in supporting your child.

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References

Australian Psychological Society. Parent Guide to Helping Children manage Conflict, Aggression and Bullying www.psychology.org.au/tip_sheets

Berkien et al. (2012) Children’s perception of dissimilarity in parenting styles are associated with internalizing and externalizing behaviour.

Brotman et al. (2011) Promoting Effective Parenting Practices and Preventing Child Behavior Problems in School Among Ethnically Diverse Families From Underserved, Urban Communities.

Sutherland & Conroy (2012). Best in Class – A classroom based model for ameliorating problems behaviours in early childhood settings.

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Spoiling Kids @ Practical Parenting

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Posted on by Leonardo Rocker (Quirky Kid Staff)

Kimberley O’Brien, our principal child psychologist, discussed ‘over-praising children’  with reporter Mercedes Maguire from Practical Parenting Magazine .. You can find useful, practical and informative advice about parenting by visiting our resources page, – or discussing it on our forum.

Check Kimberly’s and other experts comments at the Practical Parenting Website

According to Kimberley praise is great but needs to be balanced and given at the right moments or you end up with children who expect everything they do to end in a positive result, which is not reality.

The Quirky Kid runs a workshop called ‘Raise on Praise’ and other great workshops for parents.

If you have a story and would like to discuss it with us, please contact us to schedule a time. Kimberley O’Brien enjoys sharing the best of her therapeutic moments with the media. View our media appearances to-date.} else {

Toddler Behaviour: Taming Toddler Tantrums

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Posted on by Leonardo Rocker (Quirky Kid Staff)

Most parents have experienced their toddler’s challenging behaviour at some point whether it’s the “terrible twos” or for that matter, threes, fours or more. Watching your child scream, kick or throw himself to the ground in exasperation is never easy, yet as a parent, what’s important, is being able to look beyond the red-faced anger and recognise what your child is actually trying to communicate.

Many young children throw tantrums when they are experiencing a range of emotions such as anger, fear, sadness, frustration and jealousy. Regardless of your child’s motivation, it is important for parents to help their children understand that tantrums and associated behaviours such as biting, pinching and hair pulling are not always acceptable and that there are better ways to express their feelings.

Ways to Manage Toddler Behavior:

  • Use a gentle yet firm and fast response. When your child acts aggressively, unclamp your child’s hand or mouth, and say something like “no hurting”. Then, temporarily remove them from the situation, or away from the stimulus. It may take a few repetitions for children to understand that what they are doing is not allowed.
  • Consider the triggers. Sometimes children act aggressively because they are bored or seeking attention. If parents are able to recognize this then they may be able to target why the behaviour is occurring, and deal with it accordingly.
  • Use positive reinforcement. Always praise your child’s good behaviour and use resources like the Tickets – a Tool to tame Behaviour by Quirky Kid
  • Use feeling words. By assigning words to your child’s feelings or emotive states, they will eventually learn to identify how they are feeling themselves, by using such words. Although this may take a long time especially if your child is very young, eventually your child will be able to use these words to both describe and take control of her own feelings without resorting to tantrums or violence.
  • Be Consistent. It is important not to give in to whatever your child was wanting which triggered the tantrum.
  • Use therapeutic tools like the Just Like When CardsI Feel Angry or It’s Not Fair to improve emotional literacy and self expression.

What not to do:

  • While some parents may think that in order to get their child to stop a behaviour they should show them how it feels by doing it to them, this is certainly is not the recommended approach to take. Parents should never bite, pinch or pull their child’s hair just to show them how much it hurts. Regardless of the parents’ intention, this is actually a form of child abuse and is punishable by law.

How to prevent tantrums from occurring

  • Teach your child to use ‘feeling words’. Give him the tools to communicate what’s going on so that he doesn’t need to resort to tantrums or violence.
  • Use resources like the Tickets – a Tool to tame Behaviour by Quirky Kid
  • Try to avoid taking your child on outings when he is likely to get hungry or tired. Always have a snack handy.
  • Distract her from potential tantrum triggers with a story or another activity she enjoys.
  • Take note of events that trigger tantrums and try to understand what causes them in your child.

Recommended Resources:

image of ticktes behaviour tool

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*Information for this article was gathered from Kimberley O’Brien – Child Psychologist, the Raising Children Network, Children, Youth and Women’s Health Service and NSW Department of Community Services

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