Austin and Carr Chapter 7 PDF

# Chapter 6 Wagaman, J. R., Miltenberger, R. G., & Williams, D. E. (1995). Treatment of a vocal tic by differential reinforcement. Journal of Behavior Therapy and Experimental Psychiatry, 26, 35-39. Wagaman, J. R., Miltenberger, R. G., & Woods, D. W. (1995). Long term follow-up of a behavioral tre...

# Chapter 6 Wagaman, J. R., Miltenberger, R. G., & Williams, D. E. (1995). Treatment of a vocal tic by differential reinforcement. Journal of Behavior Therapy and Experimental Psychiatry, 26, 35-39. Wagaman, J. R., Miltenberger, R. G., & Woods, D. W. (1995). Long term follow-up of a behavioral treatment for stuttering in children. Journal of Applied Behavior Analysis, 28, 233-234. Watson, T. S., & Allen, K. D. (1993). Elimination of thumb sucking as a treatment for severe trichotillomania. Journal of the American Academy of Child & Adolescent Psychiatry, 32, 830-834. Woods, D. W., Long, E. S., Fuqua, R. W., Miltenberger, R. G., & Outman, R. C. (1998). Evaluating the social acceptability of persons with tic disorders. Unpublished Manuscript. Woods, D. W., & Miltenberger, R. G. (1995). Habit reversal: A review of applications and variations. Journal of Behavior Therapy and Experimental Psychiatry, 26, 123-131. Woods, D. W., & Miltenberger, R. G. (1996a). A review of habit reversal with childhood habit disorders. Education and Treatment of Children, 19, 197-214. Woods, D. W., & Miltenberger, R. G. (1996b). Are persons with nervous habits nervous? A preliminary examination of habit function in a nonreferred population. Journal of Applied Behavior Analysis, 29, 259-261. Woods, D. W., Miltenberger, R. G., & Flach, A. D. (1996). Habits, tics, and stuttering: Prevalence and relation to anxiety and somatic awareness. Behavior Modification, 20, 216-225. Woods, D. W., Miltenberger, R. G., & Lumley, V. A. (1996a). A simplified habit reversal treatment for pica-related chewing. Journal of Behavior Therapy and Experimental Psychiatry, 27, 257-262. Woods, D. W., Miltenberger, R. G., & Lumley, V. A. (1996b). Sequential application of major habit-reversal components to treat motor tics in children. Journal of Applied Behavior Analysis, 29, 483-493. Wright, K. M., & Miltenberger, R. G. (1987). Awareness training in the treatment of head and facial tics. Journal of Behavior Therapy and Experimental Psychiatry, 18, 269-274. # Chapter 7 ## Behavioral Pediatrics: The Confluence of Applied Behavior Analysis and Pediatric Medicine **Nathan J. Blum** Children's Seashore House of Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine **Patrick C. Friman** University of Nevada Behavioral pediatrics is the branch of pediatrics that focuses on the relationship between behavior and pediatric health care. The scope of the field is quite broad and includes the study of: 1) the evaluation and treatment of behavior problems in primary care settings; 2) the influence of biologic variables on behavior; 3) the effects of behaviors or emotions on biologic variables; and 4) the interaction between biologic and behavioral factors in the evaluation, treatment, and outcome of medical problems. Increased understanding of the reciprocal nature of interactions between biology and behavior and the high prevalence of behavioral concerns in pediatric settings has led to dramatic growth in behavioral pediatrics over the past 30 years. Behavior analysts have made significant contributions to behavioral pediatrics during this time and the continuing growth of behavioral pediatrics provides multiple opportunities for behavior analysts interested in working in health care settings. Further progress in behavioral pediatrics will be dependent on data-based analysis of the relationships between biologic and behavioral variables. In addition, physicians and other behavioral health professionals are being asked increasingly to develop efficient and cost-effective interventions with data-based outcome measures. Collection of observational data on problems of importance, precisely defined interventions for those problems, and data-based evaluation of outcomes are hallmarks of both behavior analysis and pediatric science. This similarity of hallmarks creates a unique opportunity for collaboration between behavior analysts and pediatric care providers to address the important questions in behavioral pediatrics. In this chapter, we provide an overview of some of the types of problems evaluated in behavioral pediatrics. We discuss important contributions of behavior analysis to the management of some common behavior problems and use the discussion of these problems to illustrate the impact of biologic variables on behavior and behavioral variables on biology. We will discuss more briefly some areas of behavioral pediatrics that could provide new opportunities for behavior-analytic research. Overall, we emphasize that there are multiple clinical behavior problems and research questions that may be best addressed through collaboration between behavioral pediatricians and behavior analysts. ## Relationship Between Pediatrics and Behavior Analysis Primary care providers are the professionals who are most likely to provide initial recommendations to families regarding behavioral or emotional concerns. The types of interventions that are most likely to be utilized are supportive counseling, behavioral counseling, or referral. Research by behavior analysts has been a major contributor to both developing and evaluating interventions for many of the common behavior problems in primary care (Cataldo, 1982; Christophersen, 1994; Christophersen & Rapoff, 1979). The principle behind many of these interventions, that behaviors are altered by their consequences, is familiar to most primary care providers. Thus, many of these interventions have been incorporated into the practice of primary care. Indeed, reviews on discipline in the pediatric literature discuss mostly behavioral interventions such as increasing parental attention for appropriate behaviors and the use of time-out from positive reinforcement for inappropriate behaviors (Howard, 1991). Reviews on the management of sleep problems discuss interventions for bedtime resistance and night waking that are based largely on social learning theory (Blum & Carey, 1996). Despite the acceptance of behavioral interventions into primary care practice, behavior analysis is yet to be widely accepted in the medical community. Lack of familiarity with the scientific basis of the field and the lack of understanding of the methodologies, especially the use of single-subject experimental designs, contribute to the lack of acceptance. Although the basic principles of social learning theory are appealing to physicians, the terminology used by behavior analysts is often not familiar to physicians, decreasing their understanding of the interventions and interest in collaboration (Allen, Barone, & Kuhn, 1993). Finally behavior analysts may be viewed as not accepting or attending to emotional factors such as anxiety or depression and family dynamic factors that are widely accepted as contributing to behavior problems within both the medical and the psychologic community. Incorporating these constructs into behavior-analytic theories, assessments, and interventions are likely to advance the field and increase its acceptance (e.g., Friman, Hayes, & Wilson, 1998). At a local level, behavior analysts interested in collaborating with physicians should consider attending and presenting at medical conferences and lectures. They may attend case management discussions and offer to help physicians implement behavioral assessments or interventions (Allen et al., 1993). When patients are referred to them, prompt data-based feedback on the interventions will be impressive to the physician, and in today's managed care environment, may be needed to justify on-going treatment to the child's insurance company. Behavior analysts can become more involved in medical professional organizations, providing a community resource for questions related to behavior. Increased collaboration between physicians and behavior analysts strengthens both fields and thereby improves outcomes for pediatric patients. ## Behavior Problems in Primary Care Settings Twenty to thirty percent of children seen in primary care have symptoms that meet criteria for a behavioral or emotional disorder (Costello et al., 1988; Horowitz, Leaf, Leventhal, Forsyth, & Speechley, 1992), and another 40% or more may exhibit behaviors or emotions that cause their parents concern and/or cause some functional impairment for the child, but do not meet criteria for a disorder (Costello & Shugart, 1992). The types of concerns commonly seen in primary care settings vary with the age of the child. With infants, parents are often concerned about excessive crying and sleep problems. In preschool children, concerns about oppositional behaviors, toileting, attentional problems, selective eating, and fears or worries predominate (Earls, 1980; Lavigne et al., 1993). Concerns about these behaviors frequently persist into the school age years, when academic and school behavior problems are also common (Kanoy & Schroeder, 1985). Minor behavior problems will often remit without the direct intervention of a professional. Thus pediatric advice about behavior problems is frequently limited to recommending that parents let their child "grow out of it." However, this approach ignores the significant stress that the behaviors can place on a family at the time that they are occurring, a fact that is highlighted by the increased risk of child abuse that occurs in association with many problem behaviors (Kempe, Helfer, & Krugman, 1987; Schmitt, 1987). Furthermore, children do not always "grow out of" their behavior problems and in most cases it is not possible to distinguish those who will "grow out of it" from those that will not. Poorly managed oppositional behaviors can evolve into much more serious problem behaviors that require extraordinary therapeutic interventions for remission (Caspi & Moffitt, 1995). Unresolved toileting problems can lead to serious medical problems such as megacolon, urinary tract infection, and the unstable bladder of childhood (Friman, 1986, 1995; Friman & Jones, 1998; Friman & Christophersen, 1986). Untreated sleep problems can lead to habitually disrupted sleep patterns, family discord, and child maltreatment (Blampied & France, 1993; Blum & Carey, 1996; Edwards & Christophersen, 1994; Ferber, 1985). Lastly, unsolved school problems can lead to incomplete education and school failure which are in turn instrumental in the development of delinquency, drug use, and ultimately criminal behaviors (Daly et al., 1998). Thus, children, families, and pediatric providers would all benefit from the availability of brief, problem specific, effective advice for parents complaining of these common behavior problems in their children. The three descriptors in the previous sentence may be the biggest obstacles to routine provision of such advice. Physicians have little time to spend with their patients and thus, if the technology available to them is not brief, specific, and routinely effective, they are unlikely to provide it to their patients. Depending on the problem, of course, they are likely to wait for the child to "grow out of it" or to refer the family for a psychiatric consult. Applying brief, problem specific, effective advice is clearly a preferable option, but such options may not be readily available. Referring the family to a behavior interventionist who specializes in providing such advice to families would be another option, but again, such individuals are not readily available. Thus, the obstacles to provision of treatment for routine child behavior problems in primary care are actually rich opportunities for applied behavior analysts. For those behavior analysts whose primary interest is research and development, defining, describing, and testing brief problem specific procedures that can be used by pediatricians is a much needed service. For those behavior analysts whose primary interest is clinical practice, applying brief, problem specific, and effective interventions for children and families referred by pediatricians for routine behavioral concerns is also a much-needed service. Reinforcers for engaging in behavior related to these services are readily available in diverse pediatric settings ranging from private practice to university medical school settings. The changes in the health care environment instigated by managed care in recent years have made those reinforcers even more available. It is beyond the scope of this chapter to discuss the behavioral management of all of the common problem behaviors discussed above. Instead, in this section we will illustrate the kind of approach we are recommending by reviewing a very common pediatric complaint, sleep disturbance, and four interventions derived from behavioral theory. In subsequent sections we will discuss subsets of toileting problems (i.e., enuresis and encopresis) in order to fortify some theoretical points. ## Sleep Problems Teaching children to go to bed, go to sleep, and stay asleep throughout the night is difficult for many families in this culture (Blampied & France, 1993; Blum & Carey, 1996; Edwards & Christophersen, 1994; Ferber, 1985). A representative survey indicated that at least 30% of families contend with this problem three or more nights a week (Lozoff, Wolf, & Davis, 1985). The difficulties reported by parents include bedtime struggles such as resistance to going to bed, fussing and crying while in bed, and night wakes with fussing, crying, and unauthorized departures from the bedroom. These problems are important because they disrupt both the parents' and child's sleep, increasing the chance of the child exhibiting irritable behaviors during the day and increasing the parents' fatigue which decreases their ability to manage these behaviors (Teitelbaum, 1977). Although behavioral pediatric advice about sleep is appropriate from three months on, its importance is much amplified if bedtime struggles continue after six months of age. One intervention for child sleep problems employed by many pediatric providers (and often parents acting on their own) involves medication. Because our concern here is with behaviorally oriented advice, we refer interested readers to reviews of sleep problems that include information on medication (e.g., Edwards & Christophersen, 1994). The cardinal component of the most effective behavioral interventions for sleep problems involves extinction. As children develop sleep habits, they often learn to associate specific environmental factors with self-quieting and the induction of sleep. Misinformed parental efforts to help their child sleep often result in problematic sleep associations that mitigate the process of falling asleep. For example, for most children sleep induction is enhanced with the presence of a parent to soothe and cuddle them and thereby ease the transition from wakefulness to sleep. These parental activities can contribute to a constellation of stimuli that control children's responses while in bed. With the parent present, rapid sleep induction typically occurs. Unfortunately, when this parent is absent at bedtime, the child is left without the stimulus that is most powerfully associated with sleep. Children's response to the typically present parent's absence resembles an extinction burst. Intense and prolonged crying is typical (Blampied & France, 1993; Edwards & Christophersen, 1994; Ferber, 1985). Because of the primordial nature of parental response to child upset, parents often directly intervene by either soothing or disciplining their child. For reasons that rest solidly on behavioral principles, these interventions often make the situation worse. The soothing parent reinforces the crying that preceded it. The disciplining parent provokes further crying, decreasing the chance of the child calming on his or her own. Many parents will then shift their tactic from disciplining to soothing which is effective in the short term, but over the long term predictably makes the problem worse. The situation presents no evident effective intervention for the parent. Soothing the child reinforces crying, discipline compounds the crying, and ignoring the crying increases its intensity and duration (Blampied & France, 1994; Edwards & Christophersen, 1994; Ferber, 1985; Lozoff et al., 1985). Not surprisingly, parents faced with sleep disturbance in their children often ask their pediatrician for advice. Three of the most commonly recommended procedures, extinction, scheduled extinction, and positive routines, are discussed below along with a fourth, self-quieting, that is newer and thus less common but has a compelling theoretical basis. **Extinction.** This approach to bedtime problems involves no visits by the parent to the child's bedroom after the child has gone to bed. In effect, the child is left to "cry it out." Generally, extinction works more rapidly than other approaches but it presents problems that mitigate its overall effectiveness (Adams & Rickert, 1989; Edwards & Christophersen, 1994; Rickert & Johnson, 1988). For example, the child's crying can be highly aversive during the first nights of implementation. If the family lives in an apartment complex, or the treatment is implemented during a season when windows are open, the crying and screaming can draw the attention of neighbors with predictably problematic consequences. Additionally, extended crying and screaming differentially affects parents. Discord is possible (probable) when crying is substantially more aversive for one parent than the other (Adams & Rickert; Ferber, 1985). Thus extinction is a straightforward behavioral approach to sleep problems in children but it has a fragile social validity. In an attempt to improve social validity, sleep researchers have developed other methods that employ extinction but decrease its aversiveness for parents with scheduling and positive routines. **Graduated extinction.** This procedure involves advising parents to ignore bedtime problem behavior for specific time intervals that gradually increase. The optimal length of the intervals has not been established empirically, but expert advice (Ferber, 1985) and some scientific study (Adams & Rickert, 1989) recommends beginning with a 5-minute interval on the first episode, 10 at the second, and 15 minutes for subsequent episodes on night one. These intervals increase over the course of a week ending with 35 minutes for the first episode on night seven, 40 for the second, and 45 minutes for all subsequent episodes and nights. Although children can tantrum for longer than 45 minutes at night, the data and a large amount of clinical experience described by Ferber suggests that very few do. A pressing question about graduated extinction is why it works. At first glance, it would seem to be the perfect procedure for teaching children to gradually cry longer and longer, culminating in a reliable 45-minute bout reproducible throughout the night. No empirically derived analysis is available, so the following is speculation. The procedure is perhaps more appropriately labeled a differential reinforcement schedule than scheduled extinction. The parents only visit the room if their child is crying and thus visits are contingent. However, increasing the response requirement to 45 minutes of crying may lean the schedule so much that the reinforcing effects of sleep supersede the reinforcing effects of parental visitation. Additional speculation can be accessed on an Internet list serve called BEHAV-AN (http://listserv.nodak.edu/archives/behav-an.html with the subject line of "mad about you"). On December 16, 1997, the popular television show by that name aired an episode devoted to the married stars employing graduated extinction to teach their six-month-old infant to sleep. The show resulted in an extended string on the BEHAV-AN list serve. **Positive routines.** This procedure involves a hybrid of extinction and a reinforcing bedtime ritual. Parents determine a bedtime they prefer for their child and the time their child typically falls asleep. Beginning shortly before the time the child typically falls asleep, parents engage the child in four to seven quiet activities lasting no longer than 20 minutes total. During the activities, the parents issue easily followed instructions and richly supply reinforcement for compliance. Although not so indicated in the original report, the instructional component is reminiscent of the high probability instructional sequence used in behavioral momentum research (Mace et al., 1988). In positive routines, as in behavioral momentum, the children follow a series of instructions with a high probability of compliance with a terminal instruction whose probability of compliance is low. With positive routines, the terminal instruction is "now stay in bed and go to sleep" or something equivalent. If at any time after the completion of the routines and the terminal instruction the child leaves the bed, the parent places them back in bed, telling them that the routine is over and it is time for bed. Crying or verbalizations are ignored. At specified intervals (e.g., one week) the parents move the positive routine back in time five to ten minutes. They continue this backward movement until they arrive at the parent preferred bedtime. For example, the child may typically fall asleep at 9:15 and the parents' preferred bedtime might be 8:15. Thus, it could take between six and eight weeks for the parents to arrive at the bedtime they prefer for their child. Experimental comparison of the positive routines procedure with scheduled extinction showed that both produced substantially improved bedtime behavior for children, but that the parents using positive routines reported significantly improved marital relations, suggesting a more socially valid procedure (Adams & Rickert, 1989). **Self-quieting skills.** In this novel procedure, the skills necessary for a child to manage bedtime upset are taught during the day. These skills involve an operant class referred to as "self-quieting” (Christophersen, 1994; Edwards, 1993; Edwards & Christophersen, 1993, 1994). Briefly, the procedure involves establishing instructional control and improved discipline through use of time-out (Christophersen, 1988) and high density nurturing or “time-in” during the day. The time-in sets the occasion for effective time-out by increasing the contrast between the two conditions (Christophersen, 1988; Solnick, Rincover, & Peterson, 1977). When children are placed in time-out for discipline infractions or ignored instructions, the exit criteria involves "self-quieting" (i.e., stopping crying and manding departure). Self-quieting is also the skill needed to establish problem-free sleep induction. The theory is that "self-quieting" is more easily learned by the child and taught by the parents during the day when they are at ease and rested than at night when they are fatigued and irritable. Once a readily produced operant class of self-quieting responses are established during the day, the parent sets the occasion for their use at night using a method similar to that used during the day. Specifically, parents provide an extended period of "time-in" at bed time (20-30 minutes of stories, hugs, etc.), say "good night," and ignore what follows. A fundamental difference between night and day procedures is in the terminal reinforcer. During the day, it is departure from time-out. At night, it is sleep. Obviously, research is needed to determine whether the compelling logic of the procedure is supported by empirical findings. Preliminary outcome evidence indicates the procedure is effective at establishing problem free bedtimes and, perhaps more importantly, it is highly acceptable to parents (Christophersen, 1994; Edwards, 1993; Edwards & Christophersen, 1993, 1994). This brief discussion of child sleep problems and their treatment is by no means complete. It includes three of the most commonly recommended approaches to the resolution of sleep problems and a relatively new procedure with much promise. The thrust of the presentation is that infant and child sleep disturbance is a very important, and common presenting complaint in Pediatrics but its treatment is unlikely to be part of conventional medical training. Behavior-analytic research has made a significant contribution to current interventions for sleep problems and provides an excellent opportunity for further behavior-analytic contributions to Pediatrics. The sleep problems discussed appear to have a fundamentally operant basis and, not surprisingly, they respond well to operant-based treatment. Please note that although our discussion suggests a relatively large amount of research has been conducted, the actual amount is small when compared with the extent of the problem in this culture - much more remains to be done. The successes obtained thus far notwithstanding, functional assessment (a hallmark of behavior analysis) has been employed very little in study of sleep problems and it is plausible that treatment failures are the result of a mismatch between treatment and problem function. Additionally, although the clinically oriented behavior analyst may feel confident in including all four of the procedures described above in their armamentarium, new procedures, especially those with high social validity, are needed. ## Influence of Biologic Variables on Behavior Few conflicts in behavioral science have been as enduring or as acrimonious as the debate between those who see human development and behavior as determined by internal biologic forces (nature) and those who view human development and behavior as determined by environmental forces (nurture). Although most recognize that both nature and nurture contribute to human development and behavior, the complexity involved in delineating the contributions of environmental and biologic variables to human development and behavior has allowed the debate on the relative importance of nature versus nurture to continue. The complexity involved in measuring environmental influences on human behavior is familiar to behavior analysts and will not be discussed here. Instead, we will discuss a common toileting problem, encopresis (soiling underwear), in which a medical condition (constipation) has been shown to contribute to the behavior. In addition, we will discuss one current area of research aimed at better delineating the influence of genetic factors on human behavior and possible roles for behavior analysts in this research. ### Functional encopresis. **Definition.** Functional encopresis, a common presenting complaint in pediatrics (3-5% of all referrals), is a disorder in which children either voluntarily or involuntarily pass feces into or onto an inappropriate location, usually their clothing (Friman & Jones, 1998; Wright, 1973; Wright, Schaefer, & Solomon, 1979). Encopresis is not diagnosed if the problem is exclusively due to an anatomic or neurologic abnormality that prevents continence. The current criteria from DSM-IV (American Psychiatric Association, 1994) are: (a) inappropriate passage of feces at least once a month for at least three months; (b) chronological or developmentally equivalent age of four years; and (c) not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation. **Physiology of bowel.** The large intestine or colon is the distal end of the alimentary tract that is sequentially composed of the esophagus, stomach, small intestines, and colon. A thorough review of the colonic system is beyond the scope of this chapter (for more thorough reviews see Weinstock & Clouse, 1987 or Whitehead & Schuster, 1985). Some rudimentary description of the system, however, is necessary to understand the biology that supplies the logic of effective treatment. The colon is a tubular shaped organ with a muscular wall. It connects the small intestine to the rectum and anus. It has three primary functions, fluid absorption, storage, and evacuation. Extended storage and planned evacuation are the defining features of fecal continence. Movement of waste through the colon is achieved through muscular contractions called peristalsis, which produce a wave-like motion of the colon walls. As the waste moves through the colon, water is absorbed creating semi-solid feces. Movement through the colon is potentiated by a variety of external events that instigate muscular contractions in the colonic wall. For example eating a meal increases colonic contractions (referred to as the gastrocolonic reflex) and moving about will have a similar affect (referred to as the orthocolonic reflex). Most of the time the rectum, the distal end of the large colon, contains little or no feces, but prior to defecation, muscular contractions in the colonic wall propel feces into the rectum. This results in distension of the rectum, which stimulates sensory receptors in the rectal mucosa, and in the muscles of the pelvic floor, resulting in relaxation of the internal sphincter which facilitates defecation. This process is involuntary, but the child can inhibit defecation by contracting the external sphincter. The child can manipulate the external sphincter and use the same three muscle groups (diaphragm, abdominal musculature, levator ani) that instigate or forestall urination to instigate or forestall defecation. The push used to complete most bowel movements is called a Valsalva Maneuver and it is physiologically and phenomenologically similar to the push needed to inflate a balloon or deliver a baby. **Etiology.** Between 80% and 95% of encopresis cases can be traced to a primary causal variable, constipation (Levine, 1975; Wright et al., 1979). DSM-IV distinguishes between encopresis with and without constipation (retention). Consistent with the theme of this section, we will focus only on those cases that include constipation. Although definitions for constipation vary, children who frequently go two or more days without a bowel movement are probably prone to constipation. A common complaint by the parents of encopretic children is that the children deliberately soil their clothing (Wright et al., 1979), but this type of accusation is usually false (Levine, 1982). The primary cause of the soiling is fecal retention (constipation). In most cases, retention is not caused by characterological or psychopathological problems (Friman, Mathews, Finney, & Christophersen, 1988; Gabel, Hegedus, Wald, Chandra, & Chaponis, 1986). Retention is usually the result of a constellation of factors, many of which are beyond a child's immediate control (Levine, 1982). These factors include a constitutional predisposition (i.e., slow gastrointestinal transit time), diet, insufficient leverage for passage of hard stools, and occasional or frequent painful passage of hard stools resulting in negative reinforcement for holding stools (Christophersen & Rapoff, 1983). Rarely, retention may be related to sexual abuse. For some children, especially those with extreme constipation and/or treatment failure, there is an increased threshold of awareness of rectal distension, a possibly weak internal sphincter, and/or a tendency to contract the external sphincter during the act of defecation (Meunier, Marechal, & De Beaujeu, 1979; Wald, Chandra, Chiponis, & Gabel, 1986). The combined effect of all these factors is a lowered probability of voluntary stool passage and a heightened probability of fecal retention. Chronic fecal retention results in fecal impaction, which results in enlargement of the colon. Colon enlargement results in decreased motility of the bowel system and occasionally, involuntary passage of large stools and frequent soiling due to seepage of soft fecal matter. The seepage is often referred to as paradoxical diarrhea because the children retain large masses of stool and thus are functionally constipated, but their colon allows passage of soft stool around the mass which results in diarrhea (Christophersen & Rapoff, 1983; Levine, 1982). That fecal impaction is related to encopresis has been established by several investigators, primary among which are Davidson (1958), Levine (1975), and Wright (1975). All independently reported that 80% of their patients had fecal impaction accompanying fecal incontinence at the first clinic visit. After his 1975 report, Levine and his colleagues developed a simple clinical procedure to identify fecal impaction from a x-ray of the lower abdomen (Barr, Levine, Wilkinson, & Mulvihill, 1979). Because of the improved diagnostic method, Levine revised his initial 80% estimate of fecal impaction's coexistence with fecal incontinence to 90% (Christophersen & Rapoff, 1979). **Differential diagnosis.** There are rare anatomic and neurologic problems that can lead to fecal retention and soiling. Anatomic problems include a variety of eccentric formations in locations of the anus which are detectable on physical exam and require medical management (Hatch, 1988). Hirschsprung's disease or congenital aganglionosis is a disorder in which the nerves that control the muscles in the wall of part or all of the colon are absent causing severe constipation. Its incidence is approximately 1 in 25,000 and it usually causes severe symptoms in infancy (Levine, 1975). Thus, the clinical presentation itself should prevent the astute clinician from mistaking one for the other. The possible exception is ultra short segment Hirschsprung's disease, which has a subtler clinical picture. However, the existence of this condition is controversial and, even if it does exist, proper collaboration between pediatrician and behavior analyst should ensure timely diagnosis. **Evaluation.** As with all behavioral pediatric conditions with a medical presentation, the initial encounter contains a "go no further" maxim - following the history, or if possible, prior to the initial visit, the behavior analyst should refer the child to a physician (preferably a pediatrician) for a medical examination. The encopresis exam should include a routine check of history and abdominal palpation, rectal examination, and sometimes a x-ray of the abdomen to determine the extent of fecal impaction. A barium enema is rarely necessary unless features of the exam suggest Hirschsprung's disease. In addition to routine behavior and psychological assessments, the behavioral interview for encopresis should include questions related to constipation. These include asking whether: 1) there is ever a long period between bowel movements; 2) bowel movements are atypically large (stop up the toilet); 3) fecal matter ever has an unusually foul odor; 4) fecal matter is ever hard, difficult, or painful to pass; and 5) whether the child ever complains of not being able to feel the movement or make it to the toilet on time. An additional question that pertains more to treatment history than to pathogenesis is whether the child ever hides soiled underwear. Affirmative answers to any or all of these questions are highly suggestive of retentive encopresis and hiding underwear indicates a history that includes some form of punishment. The encopresis evaluation is the first step in treatment. Encopresis is not well understood outside of the medical community and the child's parents are likely to be under the influence of the characterological and psychopathological interpretations that are prevalent in western culture. The parent's interpretation of the condition is also likely to influence how the children view their problem. Thus, the encopresis evaluation can actually begin treatment by providing accurate information that "demystifies" the problem. Lastly, the evaluation should include questions about diet and timing of meals. Low fiber diets and irregular meals can be contributing factors in encopresis. **Treatment.** During the past 15 years, several descriptive and controlled experimental studies have supported a multi-component approach to treatment of chronic retentive encopresis, partly derived from the pioneering work of Davidson (1958), Christophersen and Rainey (1976), Levine (1975), and Wright (1975). As indicated above, the first component can be addressed within the evaluation. Specifically, the entire elimination process including its disordered manifestations should be "demystified" (Christophersen & Rapoff, 1983; Levine, 1982). Generally this means providing information about bowel dynamics and the relationship of the problem to constipation (Levine, 1982). Second, if there is a fecal impaction it should be removed with enemas and/or laxatives (Christophersen & Rapoff, 1983; Levine, 1982; O'Brien, Ross, & Christophersen, 1986). Third, the child should sit on the toilet for about five minutes, one or two times a day (O'Brien et al.; Wright, 1975). Fourth, the parents should promote proper toileting with encouragement and not with coercion. Additionally, they should not reserve all their praise and affection for proper elimination; a child should be praised just for sitting on the toilet (Christophersen & Rapoff, 1983; Levine, 1982; Wright, 1975). Fifth, a stool softener such as mineral oil (Davidson, 1958) or glycerin suppositories (O'Brien et al.; Wright & Walker, 1977) should be used in order to ease the passage of hard stools. Sixth, dietary fiber should be increased in the child's diet (Houts, Mellon, & Whelan, 1988; O'Brien et al.). Seventh, in order to increase and maintain motility in the child's colon, the child's activity levels and fluid intake should be increased (Levine, 1982). Eighth, during toileting episodes the child's feet should be on a flat surface. Foot placement is crucial to the Valsalva maneuver (grunting push necessary to produce a bowel movement) (Levine, 1982; O'Brien et al.). Ninth, the child should be rewarded for all bowel movements in the toilet (Christophersen & Rainey; Levine, 1982; O'Brien et al.; Wright & Walker). The literature on this approach (or variations thereof) has progressed sufficiently to lead to group trials. For example, in a study of 58 children with encopresis, 60% were completely continent after five months and those that did not achieve full continence averaged a 90% decrease in accidents (Lowery, Srour, Whitehead, & Schuster, 1985). There are other examples (e.g., Stark et al., 1997). However, not all children succeed with the conventional approach and for these children augmentative methods have been developed. In a manner typical of behavior analysis, preparation for developing the methods began with study of behaviors associated with treatment failure (Stark, Spirito, Lewis, & Hart, 1990). Incorporating behavior management methods relevant to the behaviors, teaching parents to use them, and delivering treatment in a group format resulted in an 83% decrease in accidents in 18 treatment resistant children with encopresis with treatment gains maintained or even improved at six months follow up (Stark, Owens-Stively, Spirito, Lewis, & Guevremont, 1990). ## Behavioral Phenotypes The collection of genes within an individual are referred to as that individual's genotype. With the exception of identical twins, all individuals will have a different genotype. The phenotype refers to the observable characteristics of an individual determined by genetic variations or gene-environment interactions. Typically, genetic studies focus on detailed physical features that compose an individual's phenotype such as the spacing of eyes, location, form, and size of the ears, pattern of the finger print, and many other features. A large number of genetic disorders that produce characteristic physical features in an individual have been identified (