TheInvestigatingParent

A parents' resource to research-based information on parenting

Is there a science to toilet training? August 3, 2013

Filed under: Toileting — theinvestigatingparent @ 10:00 pm
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In my line of work we do toilet training with our clients (i.e., children with autism) regularly. We only use methods that are supported by research, so the 2 main methods we use are Azrin and Foxx’s rapid toilet training or a wet-alarm training. Because Azrin and Foxx’s method has shown great success, and is the most widely used, that’s the method we chose with our 2 children in training them, and the method I’m going to talk about now. Nathan Azrin and Richard Foxx developed a rapid toilet training method for the clients they worked most with in the 70’s, for children and adults with developmental disabilities. Because it was so successful they figured it should work well for typically functioning children as well. They tested their theory, and it was replicated by independent researchers several times both using professional trainers as trainers and parents as trainers, and the method was successful. Researchers found that there were some challenges to untrained parents that weren’t addressed in the book, but also found that by the pediatricians having a preparatory conversation with the parents, the concerns were largely avoidable. Not a lot of recent research has been conducted, I suspect because this is research that showed children could be trained in about a day (with some maintenance to follow afterwards) – how much better could it get? – and also because children usually eventually become trained by the age of 5 it’s not a huge area of concern for researchers. It’s too bad really, because it would be nice to get an analysis of the components that are necessary to the training and which wouldn’t matter if were dropped since it is a package that has a number of components. Azrin & Foxx (1976) published a book that is still available today outlining in a very clear way for parents the steps you need to know to follow the method successfully, called “Toilet training in less than a day.” It’s a little outdated in terms of some of the language, so it could stand to be written in today’s culture; however, the components in the training are all still relevant and very effective.

 

Curious yet? The training involves ensuring your child has met some readiness criterion for toileting (e.g., showing signs of being interested in toileting, can pull pants up and down independently), ensuring your child will follow your instructions well and teaching you how to teach that if he or she has difficulty, making the toileting experience very rewarding and motivating, and setting up the conditions to ensure maximum toileting need and maximum success. This includes getting your child to drink lots of fluids, doing wet-dry pants checks and providing reinforcers for being dry, scheduled sittings on the toilet to increase chances of peeing happening while on the toilet, positive practice/overcorrection for being wet (i.e., doing repeated practice trials of going to the toilet from a number of different locations) and a brief and gentle reprimand when wet, a lot of verbal rehearsal of being dry and the people or characters the child cares about who would care about her being dry, lots of reinforcement for all successes on the toilet, and a plan for fading out the reinforcement.

When my son turned 2 and was showing some interest in toileting we decided to take the plunge (pardon the pun). We took a weekend and started the Azrin & Foxx procedure, and were hugely successful the first day. By the second day he had no accidents, and generalized well to other locations (e.g., different washrooms at the mall). However, the Monday he was back at daycare full time, and they were neither equipped or willing to follow the maintenance phase of the training. They said they would take him every few hours to the bathroom (like what 2 year old only goes to the bathroom every 2 hours??!!). Needless to say, everything we did intensively and successfully over the weekend went down the toilet (again, with the pun :)). We have since had a long history with difficulty keeping our son dry on a daily basis, which I firmly believe is a result of the inconsistency in his early training, but also because with child care you have to pick your battles, and toileting was one I lost and I adopted a laissez-fair attitude to retain my sanity!

 

So! When our daughter turned 2, we decided we would do it RIGHT this time and learn from what went wrong the first time with our son. We started her training the weekend before 2 weeks of holidays from work. This way we could ensure that what she worked so hard at for the first day wouldn’t be undone. She did amazing! Within half a day she was independently telling me she had to pee (she may have called it “fart” or whatnot, but whatever, I’m just happy she’s telling me!). By the end of the day she wasn’t having accidents and her independent initiations had increased. On day 2 we started with some successes, some difficulty generalizing to public toilets (I have to say, at the zoo this took a lot of patience and reinforcing being in the toilet) but no accidents. Day 3 she had no problem going to the toilet anywhere, and had zero accidents all day! Leaving her with babysitters the few days following that resulted in a few bumps, but were quickly resolved. We just had to make sure the overcorrection was still used, and occasional dry checks continued.

 

Here are some tips from my experience with my kids and clients that may be helpful:

Tip #1: use the Azrin & Foxx method without eliminating any of the components.

Tip #2: make sure the “rewards” you’re using as motivators are actually reinforcing!! All too often I hear comments from parents like “oh it worked for a few days and then it wore off, so rewards don’t work.” Keep in mind that preferences change frequently for all of us and depend on how much opportunity we’ve had to imbibe in them. For example, I love cupcakes. But if I’ve already eaten 2 cupcakes today and you offer me a third one and expect it to motivate me to do something specific, you’re off your rocker (well then again, I really love cupcakes!). What I’m saying is, you have to offer a variety of reinforcers that your child can choose from, and if you get the impression they aren’t working anymore, you need to change up your supply. With my daughter I started by giving her a chocolate chip after peeing on the toilet, but when I saw her get interested in the marshmallows that were in the panty, I used those instead. I also sometimes offered her the iPad or a story.

Tip #3: you may need to reinforce “other” behaviours in order to get your child to sit on the toilet. For example, my daughter started throwing a small tantrum the third time I had her sit on the toilet, so I had to pair sitting on the toilet with reinforcement. I brought the iPad in and let her pick a video, and also gave her chocolate chips just for sitting on the toilet – both of these things were faded out quickly. If you can’t get your child in the bathroom without crying (never mind sitting on the toilet), you can provide reinforcers for closer and closer approximations to being near the toilet and then on the toilet. You might want to get these behaviours established before even starting the training.

Tip #4: the method includes 10 overcorrection trials. With my kids I found they got upset by about 3 trials, so I left it at that. I would definitely do more than one, but I’m unsure if 10 are necessary.

Tip #5: one other concern that comes up in the literature with regards to toilet training is poop withholding. There are a number of ways you can get creative with this. For example, if your child will poop in her diaper but not on the toilet, you can reinforce sitting on toilet and pooping in her diaper, and start cutting a hole in the diaper so that over time you have cut a bigger and bigger hole until she isn’t wearing the diaper anymore and is pooping in the toilet (making sure of course to provide lots of reinforcement for all poops on the toilet as you fade the diaper by cutting it). There are a number of different ways to use this concept to eventually get your child to be successful. Of course, when it comes to withholding poop, you should always keep your pediatrician in the loop to make sure there isn’t something else going on, and that frequency is monitored by a professional in case there may be medical concerns.

Tip #6: track successes and accidents. This will keep you motivated because you will be able to see your child’s progress. The Azrin & Foxx book has a couple of sample tracking sheets in the back you can use.

Tip #7: have a bottle of wine on the counter to keep yourself motivated for when your child goes to bed. Just kidding. But not. Seriously though, it is a lot of work, and it does try your patience. Plan your own reinforcers for later, and get social support from others throughout the day. For example, I texted my daughter’s progress (and some cute pics) to my husband throughout the day. Be prepared that you will have frustrating moments and may even want to give up at some points, but it will be worth it and it’s really only one day with some follow up work for the next week or so. I did follow up my day with a glass, I’ll tell you that!

 

Cheers!

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The W.H.O….and don’t forget about the WHY about breast feeding duration June 1, 2012

Filed under: Breast feeding — theinvestigatingparent @ 9:25 am
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Time magazine recently posted some controversial photos about mothers breast feeding their not-so little children. The cover depicted a hot mom posed somewhat provocatively with her 3 or 4 year old son standing on a step stool with her breast in his mouth, looking at the camera. This sparked a debate on Facebook pages and blogs like wild fire. I saw many defensive comments from mothers citing the World Health Organization (WHO) recommendations about breast feeding to age “2 and beyond.” In North America this appears to be an attachment parenting debate. Many argue that it’s completely natural in many other societies and that it’s only recently in western culture that it’s not as accepted.

I didn’t remember the WHO recommendation of to “2 and beyond” from when I had my first baby, so I thought I would check out the change and see why.

First, the recommendations include breast feeding exclusively to 6 months, and then using breast milk as complimentary. There are many good and sound research based reasons for that, but that’s another blog post entirely. In this post I’m most concerned with why the change to “2 and beyond.”

The WHO has a comprehensive promotional plan for their newer breast feeding recommendations. The reason for this is in developing countries (formerly known as 3rd world countries) 35% of children under the age of 5 continue to die today due to malnutrition.  The malnutrition has to do with access to adequate food and supplies. This is a very serious socio-economic problem, not an attachment parenting style problem. The WHO’s recommendation is to protect the lives of children who could die if they didn’t receive nourishment from anadequate food source. Breast milk, while not adequate for babies over 6 months of age, could help. In North America, for families who don’t have a socio-economic problem, as long as the children aren’t refusing food and drink, there is no longer a nutritional reason to receive breast milk over 1 year.

The moral of the story is to remember that while sources like the WHO are invaluable,  it’s also important to know and question the WHY.

Kirsten

 

How quickly they crumble…and how I may need a vacation after my vacation April 1, 2012

Filed under: Sleep — theinvestigatingparent @ 5:35 pm
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I have personally had one of each – one child who was a trouble sleeper from the beginning, and one child who was a dream sleeper from the beginning – not to mention my clinical experience. But I really didn’t expect my perfect sleeper to deteriorate so quickly from traveling and disrupting her routine for a mere 4 days (and counting).
We arrived in Orlando, FL well past bedtime after a day of traveling, the baby had 1 skipped nap, had 1 very short cat nap, and a very late bedtime. Research (and my clinical and personal experience) shows that overtired children make for wake ups at night. Generally I can deal with that by the next night, but we started out all in one little hotel room. [As an aside, we were assured there were balconies, so our plan was to sit out on the balcony until my husband and I were ready for bed. My new question will be how deep are the balconies? They were maximum 1.5 feet deep, so I don’t even understand the point in them, except so the hotel can claim they have balconies. Needless to say, my husband and I spent a few disappointed hours “hanging out” in the bathroom.] So in an effort to save my 3 year old from being woken up by the 8 month old, I responded to every little cry the baby had by picking her up and shushing her, and even nursing a few extra times than I normally would have. Needless to say she was not quite herself the next morning having her sleep so disrupted. Given the late bedtime, they both – wait for it – woke up AN HOUR EARLIER THAN USUAL. A lot of parents (clients and friends) tell me that they try to keep their children up later in the hopes they won’t get up so early – it doesn’t usually work and I’m afraid this will have the opposite result. The evidence has shown that once the child is overtired, they will usually not only wake up earlier, but likely begin to wake up throughout the night.
My response to this is usually to put them to bed an hour earlier. One or two nights of that, and ridigly ensuring naps, usually takes care of the fallout – this is a clinical recommendation from the research and works every time. However, did I mention we’re in Orlando? We did Disney’s Magic Kingdom the next day, the baby had one really good nap but skipped the next ones, and although we had intended to be back in time to put them to bed early, it ended up being late. We did arrange to be moved to a suite while we were gone. We thought we would put the kids to bed in the bedroom, and then transfer them out into the living room area when we were ready for bed. Anyway, when we got back from Disney none of our luggage was there. Once we finally got it and got the kids bathed and ready for bed it was once again, quite late. We didn’t want to disturb the kids, so we thought we’d try it another night and keep them in there with us. Did you guess what happened? Well my 3 year old must have the sleep fairy on his side, because he was always the trouble sleeper, and he is doing not bad. Don’t get me wrong – he’s sleeping through the night – but he’s waking up an hour earlier than usual, and you can TELL in his behaviour (see one of my earlier posts on ADHD mis diagnosis). My 8 month old, good little sleeper, woke up so many times I didn’t count and couldn’t remember. I think I maybe slept 45 minutes consecutively, and then they were up again an hour earlier than usual.
All of this really shouldn’t be a shock to me, I  know the research, I’ve written a book (coming in September), I counsel parents in talks and clinically, yet I still made the same rookie mistakes. Last night when my husband and I went to bed, we moved the baby into the living room area, so my husband, myself, the 3 year old, and of course the baby too, could get a better night’s sleep. I still went into the room more than I would have if we were at home to comfort and check on her, but there was a definite improvement over the previous nights. Tonight I will have to resist even more. It’s hard. My little girl is so very perfect, and so infrequently cries that it’s really hard to just let her cry. But let me paint you a picture –  for those of you who think it’s horrible to let a baby cry and not provide comfort. My perfect little girl is normally so happy and smiley that people continuously come up to us to interact with her. She is just a joy to be around. The past few days, since I have begun to comfort her at night, her sleep has gotten more and more fragmented and interrupted, naps are ridiculously difficult for her, she is barely smiling, looks a bit like a zombie, cuddling into me at the pool earlier today like she wanted to sleep right in the water, eyes completely red rimmed, miserable and crying off and on throughout the day. This is the complete crumbling of a wonderful baby within only a few short days. It made me think about how many parents in the interest of attachment and being afraid to let their children cry, ended up causing their children more harm than good? I don’t like to hear my baby cry, but I have argued before and I argue now – it is MY need to comfort her that is affected the most rather than her need to be comforted. Her need is sleep, and she is so tired she cries. She doesn’t know any better, but I do, and I know – because I believe in the evidence and I thankfully also have the clinical experience – that it’s a small price to sacrifice on my end for the short run of hearing her cry, when in the long run she will be a well rested and happy baby that no longer really cries at night.
 

Mis-diagnosed ADHD or Sleep Disorder? March 12, 2012

Did you know that the symptoms of sleeplessness are so alike those of Attention-Deficit-Hyperactivity Disorder (ADHD), that many children have lost their diagnosis of ADHD simply by having their sleep treated? For example, tantrums, hyperactivity, inattention, and other daytime problem behaviours are common symptoms of sleep loss in children (well, adults too for that matter – we just know how to control ourselves better), and also symptoms of ADHD. In fact, sleep researchers put out a call to Pediatricians in a well known journal in 2011 to encourage them to question parents about their child’s sleep habits before giving a potential mis-diagnosis of ADHD. If your child, or anyone you know has a child who has been labeled with ADHD – take a look at their sleep habits before resorting to other treatment. Are their sleep needs being met? Do they seem tired or groggy when they get up in the morning? Are they showing signs of being tired long before their regular bedtime?

Could you imagine your child being labeled with ADHD and medicated, on an IEP at school, having many behavioural problems, when all along it was due to a sleeping problem? This is not to say that all cases of ADHD are not real cases of ADHD, but it’s significant enough that it’s worth a second investigation.

My son is a little more flexible with his sleep now that he’s getting a little older, but still has his moments. If he got to stay up really late because of a holiday or a family get together, my husband and I always know we are going to pay for it later. Last summer his cousins came out to the lake to visit us one day, and they were having so much fun together we let him stay up until 9:30 (bedtime was usually 7). The next few days were filled with CRAZY tantrums every time he didn’t get something he wanted, or didn’t want to do something. Needless to say, he went to bed early several nights in a row, and all was fixed within a week. But imagine what his behaviour could have been like had we let him stay up past his bedtime night after night? If I didn’t know what his sleep needs were, that could very well have been our life. And I wouldn’t have known what to do with him or how to cope, and it’s very easy to see how that would spiral into a case of ADHD when I took that complaint to the Pediatrician. Because I have been so diligent with my son’s sleep needs, when he starts to behave that way I know he either needs to go to bed early at night, or he has a possible ear infection (that’s another story).

-Kirsten

 

Getting them to stay in bed once they’re in there! February 28, 2012

Filed under: Sleep,Uncategorized — theinvestigatingparent @ 2:24 pm
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When my son was 18 months he started to absolutely hate his crib. My husband and I decided to get him a bed so bedtime and sleep didn’t become this awful place for him. The first night we put him in the bed I was terrified! I imagined that he’d be running out of the room continuously and I had a plan ready in case. To my amazement, he stayed in bed and continued to go to bed pretty much perfectly. A lot of parents aren’t so lucky, and I’ve certainly seen my fair share of that in my work! In the sleep seminar I gave a few weeks ago, one of the common problems that came up was “how do I get him to stay in bed once I say good night?” There are 3 components to this answer:

1. It’s so important to make sure kids are in bed at their optimal sleep time. Remember that sleep experts indicate the optimal bed time for young children is between 6-8 pm, with 8 pm being on the late side. (For more on this topic see my previous post on Feb. 17 called “sleep needs for children.” If your child is up past his or her optimal sleep time, you’re likely to see an overtired child pulling out all the stops and not going to sleep properly at bedtime. I can always tell with my son when it’s just a little past his sleep window as he asks for everything under the sun at bedtime “I need another cuddle,” “drink of water,” “just want to tell you something,” “I’m hungry”… When I get him to bed on time, he’s an angel and there’s not a peep.

2. Be prepared by the door and give as little attention to him or her as possible. Particularly if you are trying a new sleep routine or moving from a crib to a bed, be prepared to hang out outside your  child’s bedroom until he or she stops coming out. As much as we like to blame our little rug rats for their behaviour, I’m sorry to say, but the majority of  child bedtime problems are well-meaning parental attention maintained. So have a little camp out by your child’s door, with your book or laptop and a glass of wine (as necessary of course!), so that you can nip the fun out of their bud. With as little attention as possible, walk him back to bed, put him in therand leave the room, and close the door. If you need to say something, keep it simple – e.g., “it’s bedtime, I love you, good night.” The first time you may need to repeat this several times (or 65), but don’t worry, be consistent and it will pay off soon.

3. Did I mention be consistent? This is THE most important tool in your toolbox. Kids are smart little cookies and they know when mom and dad are going to give in and exactly which buttons to press. Don’t underestimate them! Stick to your guns. Don’t bring them to bed with you, read 12 more stories, allow 4 more glasses of water…. Have a set routine and stick to it and they will believeyou when you say “it’s bedtime, I love you, now go to sleep.”

-Kirsten

 

What to Remember for Sleeping After Illness February 12, 2012

Filed under: Sleep — theinvestigatingparent @ 4:57 pm
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It’s like a nightmare I remember only in my…well..dreams. My perfectly sleeping 7 month old daughter has a fever and barely slept a wink all night. Meaning my husband and I barely slept a wink last night. This is the girl who I normally can just waltz into her room, put her in the crib, and say “night night sweetie I love you,” leave the room and not even a peep. Last night I couldn’t put her down without her bursting into tears and crying for long periods of time. I would just rock her to sleep, slowly start to move her over the railing of the crib to put her down, and her eyes would pop open (like one of those dolls we had when we were kids) and she would start crying. So I spent much of the night sleeping off and on in the rocking chair holding her. It was like stepping back in time to when my son was a baby. He was the opposite of my perfectly sleeping 7 month old. He was the inspiration for my sleep training book, this blog, you get the picture. My husband and I spent many hours singing lullabies and doing strange rain dances through the night to get him to sleep. Anyways, I digress. But thinking back to that experience did lead to my train of thought to “here we go again, she’s never going to sleep again, I’m never going to sleep again…”

I had to start using some positive self-talk, and remind myself that I’ve been here before, I know what to do, and it will all be fine soon. I started planning for the worst case scenario. Anytime kids get sick we tend to do all the things we should and shouldn’t, to give them comfort, just to get ANY sleep, to watch over them. Once the kids are better this often leads to a need for some re-training – is it on our part or theirs? I dread that once my daughter is better that she won’t go back to being a perfect little sleeper. Maybe she will, and maybe she won’t. So I have to prepare myself that I will probably have to invest in some of the basics for sleep training. After her bedtime routine, I will put her down, tell her I love her and leave the room. I have to be prepared that some crying will be involved, and it will be okay. I can go and check on her if I need to, trying to provide as little attention as possible, and leave the room. She will get it. Now its just a matter of…how long is it going to be until then?

– Kirsten

 

Under Construction! January 29, 2012

Filed under: Uncategorized — theinvestigatingparent @ 11:07 pm
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This stite is currently under development. It will be a source of weekly parenting tips based on actual research, supplemented with examples of how I have been able (or not) to apply these to my own life and my own parenting. I hope it will be helpful to you, by cutting down the time it takes to find good sources and make evidence-informed parenting decisions. You will find topics about what actually works, that is, been shown through good research what really works, rather than my own opinion. Of course my opinion will be given as well 🙂 but based on the information I have found for myself (and for you).

Topics coming soon: How to REALLY get your kids to sleep and stay asleep

 

 
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