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Encopresis and incontinence, Late Elementary

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http://www.pbisworld.com/forum/#/discussion/2/intentionally-wetting-pants-in-late-elementary\n\nWith home issues and mental health issues, it may be that no interventions will be effective until those things are resolved or under control. If the student perceives their world as spinning out of control and they feel no control over anything, this could be the student's way of gaining control. Or it could be involuntary and a symptom of being overly stressed and insecure. \n\nIf the student does experience a high level of stress at home, it may be helpful to teach the student a specific set of coping skills. For example, sitting down with the student and brainstorming 5 things the student can do when they feel stressed (and you may have to explain to the student what stressed is and how it feels). These 5 coping skills could be written on a paper or laminated and kept at the student's desk. When the student feels stressed, they take out this list and do one of the 5 strategies. If the teacher notices the student appearing to be stressed, then the teacher and the student could set up a secret signal whereby the teacher gives the signal and the student understands that this signal means they need to get out their list and do one of the 5 coping strategies on the list. The teacher could keep this list at their desk as well so the student will always have access to it one way or another. Some examples of coping skills may be:\n-Close eyes and take 3 deep breaths\n-Count to 10 then take a deep breath\n-Think about a place that makes you relaxed and happy. Specifically, think about what that place sounds like, feels, like and looks like\n-Cover your ears so you cannot hear anything and breath in and out slowly and deeply. Imagine that each breath going in is a wave on a beautiful tropical beach gently rolling up the shore on to your feet. Then imagine that each breath going out is the same wave gently rolling back into the water.\n-Doodle, draw, or color (could draw anything or draw how feeling)\n-Write in a journal\n-Write your worries on a paper and then tear it up and throw it away\n-Roll your neck in circles to get the tightness and stress out\n-Stretch your arms and legs while sitting in your seat to loosen up\n-Rub your finger nails as the smooth texture can be calming and soothing\n-Lean you head all the way back with your mouth open and your eyes closed for a moment\n-Take a short break by getting a drink or throwing something away\n-PBIS World page on coping skills\n\nIf no one has sat down with the student and had a talk about the behavior and its impact on their functioning in school as well as the wishes of everyone for the student to have positive peer relationships and school functioning, this could be helpful. It could be framed in a positive and encouraging manner, like \"Johnny, we really love having you in school and in class. You're a great contributor and have wonderful things to say and add. We want to keep you in class and contributing more because the other students are missing out on what you have to say and think when you leave to change or when you have to go home. We'd like to brainstorm 3 ways we can do this...\"\nKeeping it more open ended like that might give some good insight as to what the student thinks the actual problem and solution is. It may be the solution has nothing to do with the behavior or has no logical connection, but for some reason does in the student's mind. \n\nIt may be that the interventions and problem solving ideas are in fact directed and focused totally on the wrong thing. Posing some open ended questions and choices could help uncover these unthought of avenues.\n\nAnother thought is that the student may get some kind of sensory stimuli through the behavior. Perhaps the feeling or sensation of being wet or soiled is something the student likes. If this were the case, then providing alternative ways to get this sensory stimuli may help. Some ideas may be having velcro glued under the desk so the student could rub it. Having the student sit on a seating or bumpy disk may provide some sensory stimuli to replace the undesired behaviors. Perhaps some wrist and ankle weights or a tight fitting vest may provide additional sensory stimuli. You could also try having the student sit on a yoga ball rather than a seat. This can provide the brain extra stimuli and reduce undesired behaviors.\n\nIt could be helpful to put the student on a structured bathroom schedule, where the student has a visual schedule on their desk and just goes to the bathroom every certain amount of time whether they have to go or not. When they return, they check off that time on their visual schedule. The visual schedule could be laminated so they could use a dry erase marker to make the checks and then erase it at the end of the day for the next day. If you know what the student likes or incentives they would work for, perhaps this chart could be used as an incentive chart as well. If the student goes to the bathroom and checks all the time slots off for the entire day, then at the end of the day, they get an incentive, whether that is time on the computer, talking to a friend, talking with an adult, helping in the office, etc. You would not be rewarding them directly for using the bathroom rather than going in their pants, but it may be a first step that leads to fewer incidents. Just rewarding the student with incentives to even be in the bathroom frequently whether they go or not may lead to them just going while they are in there. If the student cannot make it an entire day, then this could be broken up into smaller intervals for earning incentives. For example, at lunch then at the end of the day, or even smaller intervals if necessary. If you were to do something like this, be sure to sit down and explain it all with the student and practice it. Even explaining the obvious, for example, that when the visual schedule time slots match the time in class, you stand up, walk to the bathroom door, open the door, go in, use the bathroom, wash your hands, walk back to your seat quietly, make a check on your visual schedule, and get back to work. The schedule would have to be done very discretely, so you would want to have it smaller and in a place where it is only visible to the student. \n\nOne last thought is about the actual physical location, design, lighting, toilet, etc, of the bathroom itself. Perhaps the student may go to the bathroom if they could use a different bathroom in the school somewhere. Maybe for some strange reason they do not like using the one they have to use. Or perhaps the bathroom tissue is causing them to choose not to go. Maybe its the echoing in the bathroom. Perhaps they are afraid of the bathroom or being alone and would go if they had a bathroom partner that stood outside the door to guard it for them. These are all kind of out there, but I thought I'd throw them out there anyway."}" data-sheets-userformat="{"2":961,"3":{"1":0},"9":0,"10":1,"11":4,"12":0}">Presenting Behavior:
Please describe the behavior:
Encopresis and incontinence (reportedly not due to medical condition)

How old is the student?
Late elementary

Where and when does the behavior occur?
At school almost daily

Frequency and duration of behavior?
Almost daily

What happens before and after behavior?
Student changes clothing and diaper then returns to class

What does the student get from engaging in the behavior?
Unsure

What is the emotional state of the student during the behavior?
Usually appears unresponsive and unaware

Who is the behavior directed at?
Unsure

Is the behavior intentional or involuntary?
Perhaps involuntary

Relevant health and mental health conditions?
Documented mental health problems. Home issues with legal involvement.

Student strengths and interests?
Seems generally nice, appears to enjoy school and playing outdoors. Talkative on indivudual basis.

Have you noticed any patterns?
No. Overall behavior has been occuring for many months

Other information and comments:
Home aware of problem behavior in school but seems unaware of pressure it puts on student in social setting. Hygiene skills seem lacking.

Possible Interventions:
This sounds like a very difficult and layered case. I had a similar question not too long ago and gave a reply. You can view it here on the PBIS World Forum: http://www.pbisworld.com/forum/#/discussion/2/intentionally-wetting-pants-in-late-elementary

With home issues and mental health issues, it may be that no interventions will be effective until those things are resolved or under control. If the student perceives their world as spinning out of control and they feel no control over anything, this could be the student's way of gaining control. Or it could be involuntary and a symptom of being overly stressed and insecure.

If the student does experience a high level of stress at home, it may be helpful to teach the student a specific set of coping skills. For example, sitting down with the student and brainstorming 5 things the student can do when they feel stressed (and you may have to explain to the student what stressed is and how it feels). These 5 coping skills could be written on a paper or laminated and kept at the student's desk. When the student feels stressed, they take out this list and do one of the 5 strategies. If the teacher notices the student appearing to be stressed, then the teacher and the student could set up a secret signal whereby the teacher gives the signal and the student understands that this signal means they need to get out their list and do one of the 5 coping strategies on the list. The teacher could keep this list at their desk as well so the student will always have access to it one way or another. Some examples of coping skills may be:
-Close eyes and take 3 deep breaths
-Count to 10 then take a deep breath
-Think about a place that makes you relaxed and happy. Specifically, think about what that place sounds like, feels, like and looks like
-Cover your ears so you cannot hear anything and breath in and out slowly and deeply. Imagine that each breath going in is a wave on a beautiful tropical beach gently rolling up the shore on to your feet. Then imagine that each breath going out is the same wave gently rolling back into the water.
-Doodle, draw, or color (could draw anything or draw how feeling)
-Write in a journal
-Write your worries on a paper and then tear it up and throw it away
-Roll your neck in circles to get the tightness and stress out
-Stretch your arms and legs while sitting in your seat to loosen up
-Rub your finger nails as the smooth texture can be calming and soothing
-Lean you head all the way back with your mouth open and your eyes closed for a moment
-Take a short break by getting a drink or throwing something away
-PBIS World page on coping skills

If no one has sat down with the student and had a talk about the behavior and its impact on their functioning in school as well as the wishes of everyone for the student to have positive peer relationships and school functioning, this could be helpful. It could be framed in a positive and encouraging manner, like "Johnny, we really love having you in school and in class. You're a great contributor and have wonderful things to say and add. We want to keep you in class and contributing more because the other students are missing out on what you have to say and think when you leave to change or when you have to go home. We'd like to brainstorm 3 ways we can do this..."
Keeping it more open ended like that might give some good insight as to what the student thinks the actual problem and solution is. It may be the solution has nothing to do with the behavior or has no logical connection, but for some reason does in the student's mind.

It may be that the interventions and problem solving ideas are in fact directed and focused totally on the wrong thing. Posing some open ended questions and choices could help uncover these unthought of avenues.

Another thought is that the student may get some kind of sensory stimuli through the behavior. Perhaps the feeling or sensation of being wet or soiled is something the student likes. If this were the case, then providing alternative ways to get this sensory stimuli may help. Some ideas may be having velcro glued under the desk so the student could rub it. Having the student sit on a seating or bumpy disk may provide some sensory stimuli to replace the undesired behaviors. Perhaps some wrist and ankle weights or a tight fitting vest may provide additional sensory stimuli. You could also try having the student sit on a yoga ball rather than a seat. This can provide the brain extra stimuli and reduce undesired behaviors.

It could be helpful to put the student on a structured bathroom schedule, where the student has a visual schedule on their desk and just goes to the bathroom every certain amount of time whether they have to go or not. When they return, they check off that time on their visual schedule. The visual schedule could be laminated so they could use a dry erase marker to make the checks and then erase it at the end of the day for the next day. If you know what the student likes or incentives they would work for, perhaps this chart could be used as an incentive chart as well. If the student goes to the bathroom and checks all the time slots off for the entire day, then at the end of the day, they get an incentive, whether that is time on the computer, talking to a friend, talking with an adult, helping in the office, etc. You would not be rewarding them directly for using the bathroom rather than going in their pants, but it may be a first step that leads to fewer incidents. Just rewarding the student with incentives to even be in the bathroom frequently whether they go or not may lead to them just going while they are in there. If the student cannot make it an entire day, then this could be broken up into smaller intervals for earning incentives. For example, at lunch then at the end of the day, or even smaller intervals if necessary. If you were to do something like this, be sure to sit down and explain it all with the student and practice it. Even explaining the obvious, for example, that when the visual schedule time slots match the time in class, you stand up, walk to the bathroom door, open the door, go in, use the bathroom, wash your hands, walk back to your seat quietly, make a check on your visual schedule, and get back to work. The schedule would have to be done very discretely, so you would want to have it smaller and in a place where it is only visible to the student.

One last thought is about the actual physical location, design, lighting, toilet, etc, of the bathroom itself. Perhaps the student may go to the bathroom if they could use a different bathroom in the school somewhere. Maybe for some strange reason they do not like using the one they have to use. Or perhaps the bathroom tissue is causing them to choose not to go. Maybe its the echoing in the bathroom. Perhaps they are afraid of the bathroom or being alone and would go if they had a bathroom partner that stood outside the door to guard it for them. These are all kind of out there, but I thought I'd throw them out there anyway.

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