Bedtime Blues

Getting a child to go to bed, and stay in bed the entire night, is a common concern of families I work with.  When I get asked to help them with this concern, I generally do a few observations prior to beginning the intervention.  I admit it's a little awkward for me being in their home when everyone is getting ready for bed.  I don't know that I would want someone in my home when I am usually just wanting to relax before going to bed.  However, if parents are frustrated enough to have to ask someone to help them with the bedtime routine, I suppose it would make it a little easier.

So,  I do my observations, figuring out the typical bedtime routine for the kiddo as well as the family.  I always tell the parents to just do whatever they normally would do.  If they act differently than usual, it may skew my observational data and possibly affect the effectiveness of the intervention that I implement.  After the observations, I write up my behavior intervention plan. 

That's when the article for this blog comes in.  There are many different interventions that have been tried to get a child to go to bed  appropriately and stay in their bed.  This article discusses many of these interventions.  The article was called: Behavioral Parent-Training Approaches for the Treatment of Bedtime Noncompliance in Young Children.  The authors are Camilo Ortiz and Lauren McCormick.  It can be found in the Journal of Early and Intensive Behavior Intervention, Volume 4, Number 2 2007, pgs 511-525.  Here is a link to the article: http://www.jeibi.com/

Here are the interventions that they reviewed along with a brief description of each :

Unmodified Extinction/Systematic Ignoring - In this intervention, the parents put the kid in bed and leave the room, ignoring everything that child does between getting placed in bed and waking up in the morning.  It was stated that 21 studies have found this to be effective  I don't ever ask parents to do this as an initial intervention.  Listening to a child crying all night is not too much fun for parents.

Graduated Extinction - This involves the parents gradually reducing the attention that parents give to the child after putting them to bed.  For example, the first time, they may wait 5 minutes before responding to their child's crying or whining.  Then they may wait for 10 minutes the next night. This would continue until the child goes to sleep without gaining attention from their parents for crying/whining.  The authors stated that 14 studies have found this to be effective.  I'm currently doing something like this for one of my families and have had good success with it in the past.

Bedtime Pass - This is when the parents give the child a free pass to get out of bed.  This could be used to get a drink, go to the bathroom, hug the parents, etc. I have done this before as well.  Sometimes starting with 3 passes, then gradually decreasing how many are given.  This is generally popular with parents.

Positive Routines - This is one I'm not familiar with.  The parents wait until the child starts getting sleepy, then has the child do a routine of pleasurable tasks so that those become paired with the feeling of being tired.  Eventually, parents get the child to go to bed at the desired time while continuing to run through the routine. This was found to be effective in some studies as well.

Fading/Response Cost - I haven't done this one either.  The parents begin by putting the child to sleep at a later time so that it is more likely that the child will fall asleep, and then gradually get them to go to sleep at the desired time. If the child does not fall asleep within a certain amount of time, the parents put the child to bed at a later time the next night.  The response cost part that can be done with it is that if the child doesn't fall asleep within a certain period of time, the child is taken out of bed and has to stay up for one hour before going back to bed. I'm not too sure about this one.  I'm worried that it would be more stressful on parents than on the child.

Cosleeping - Basically this is when parents stay in bed with their kid. I don't generally encourage this, but if it is occurring prior to me starting with them, then I work on a fading procedure (not the Fading/Response Cost one) where I have the parents stay in there for a certain amount of time before getting out of the bed, gradually fading them out of the room entirely.

Social Stories - In this one, the parents read a social story to the child about going to bed appropriately.

The authors stated that generally these interventions are not done alone, but are usually paired with another intervention.  Of course it depends on the situation, but I usually use a couple of techniques at the same time.  One that I use pretty consistently is some kind of a fading procedure, whether it's fading parents out of the room, fading something out of the kids room, or fading parent attention to the child. 

Here's where you guys come in again.  Like I said, I get told a lot by parents that this is a concern.  I try to work with the family to make sure that the intervention works for them and their nightly routine.  Do you think that the positive routines intervention would work?  What do you think about the other interventions?  Are there other things that you have tried that have or haven't worked?

Pediatric Feeding Issues

Ok, so here goes nothing.  The first blog.  No pressure!  I've said that I want to focus on the latest research when it comes to kids with special needs.  When I find an article that seems interesting and of value to me in my work, I want to be able to share it with you.  Besides, I may be using the findings of my latest research on your kids!  I'm not going to get into all of the technical jargon of the articles on these blogs, but I will post a link to the article for those of you who love looking at the graphs and getting more information like I do.

The first article that I want to share with you all has to do with eating issues.  I have worked with lots of kids who I have had to help expand the variety of foods that they will eat.  A lot of them would only eat certain foods (chicken nuggets, chips, etc.)  Those actually sound pretty good right now, but probably because I'm hungry. Focus, Lisa! 

Anyway, the name of the article is "A Comparison of Sensory Integrative and Behavioral Therapies as Treatment for Pediatric Feeding Disorders." 

It is written by: Laura R Addison, Cathleen C Piazza, Meeta R Patel, Melanie H Bachmeyer, Kristi M Rivas, Suzanne M Milnes, Jackie Oddo,

 

and can be found in: J Appl Behav Anal. 2012 Fall; 45(3): 455–471. doi: 10.1901/jaba.2012.45-455

 

Here is a link to this article:

http://www.ncbi.nlm.nih.gov/pmc/issues/215201/

Basically, the authors did a study to determine if the two kids in the study would eat more food and engage in fewer inappropriate behaviors (turning away, pushing the spoon away, spitting the food out, etc.) if the therapists gave the kids access to preferred toys and attention or if the kids did sensory integration activities right before eating.  In both instances, they determined beforehand that the kids did those icky behaviors to escape from having to eat the food or drink the drink.  So they implemented "escape extinction" which means that the therapist basically didn't let the kids get out of eating by doing those icky things.  Instead, the therapist just held the spoon at the kids lips and continued to try to have them eat the food/drink the drink.  They didn't say anything to the kids about what they were doing at the time. 

Long story/article short, they found that both kids ate more food and had fewer icky behaviors when the did the "escape extinction" thing as well as letting the kids have access to fun stuff and attention throughout the eating sessions. 

Here are some things to consider though:

• There were only two kids in this study
• The kids were 1 and 3
• Both kids had other diagnoses in addition to feeding issues

So here are my questions for you.  That's right, you don't get off easy when you sign up for my blog. I want your opinions and feedback.  How else am I going to learn?  I can't depend on research articles alone!

1. If you have a kiddo who is a picky eater, do you think it's more of a sensory thing for your kiddo, or a control thing, or both? Something else?
2. How do you guys feel about having a therapist hold the spoon in front of your child's mouth the whole time while trying to get them to eat?  Maybe I should ask how would you feel if you were the one that was asked to do that?
3. This kind of goes along with the last question: In some studies, if the kiddo spits the food out, the therapist will scoop it back up (as long as it wasn't on the floor or whatever) and feeds it back to the kiddo.  How do you feel about that? 

I think this article is a good article to start with.  I know it's something that many parents have to deal with, whether or not they have a kid with special needs.  As much as I've enjoyed writing this first blog, I really must go eat.  Somehow, after those last two questions though, chicken nuggets and chips don't sound quite as good.

Happy eating and feeding!