Thursday, March 15, 2012

Elimination Disorders: Enuresis and Encopresis written by our Guest Psychologist Dr Nicole Arthur Jindalee Brisbane

Dr Nicole Arthur

Bladder and bowel controls are two important developmental
tasks during toddlerhood and preschool age. Children are 
generally anticipated to develop these controls around 4-5
years of age. Still, occasional wetting and soiling could be expected after these ages.

However, when toileting problems are persistent without 
medical reasons (e.g., side effects of diuretics/laxative or
medical conditions; namely, bladder infection or diabetes),
an assessment for the presence of an elimination disorder
should be considered.

Types of Elimination Disorders

Elimination disorders can be grouped as Enuresis, where wetting is the main concern, and Encopresis, where soiling is the key feature. 

Enuresis involves repeated inappropriate voiding of urine (e.g., into bed or clothes). This could be involuntary or voluntary, although the former is more likely. Normally, enuresis should be considered only when the child is at least 5 and when the wetting occurs at least twice weekly for at least 3 months.

Although enuresis can occur at any time, it is more common at night than during the day, with 80% of children with enuresis wetting at night only. 

Encopresis involves repeated inappropriate passages of faeces (e.g., into bed or floor). Similar to enuresis, this is most often involuntary. Normally, the diagnosis of encopresis should be considered only when the child is at least 4 and when the soiling occurs at least once a month for at least 3 months.

The majority of Encopresis occurs as a result of initial constipation which leads to painful defecation, toilet avoidance, further constipation, and then leakage. In rare cases where no evidence of constipation is observed, Encopresis is associated with inadequate bowel control or deliberation.

It is important to note that although some children with toileting difficulties have never mastered bladder or bowel control, others had been successfully toilet trained for at least a year but later developed toileting problems. In the former case, the elimination disorders could be considered as primary whereas the latter case as secondary. This applies to both Enuresis and Encopresis,
Commonly Associated Symptoms 

Anxiety and avoidance of situations or social activities that could lead to embarrassment due to incontinence (e.g., school, sleepover)
Lower self-esteem
Anxiety in general
Sleep disturbance
Impaired social and family functioning

Both Enuresis and Encopresis are reported more often in boys than girls (with the ratio of 3:2 for Enuresis and 4:1 for Encopresis). Also, they occur at different rates for children of different ages. Younger children are more likely to experience toileting problems than the older ones.

Enuresis occurs in approximately 10-15% of children at age 5; 5-6% at age 10, and 1% of teenagers and adults.

Encopresis is less common than Enuresis. Approximately 1-2% is reported in children at age 5 and 0.5-1% at age 10-12. Approximately 25% of children with Encopresis receive a diagnosis of Enuresis as well.
Possible Causes: 

As with many mental health conditions, the exact cause of Elimination Disorders is not fully understood. Different children develop these difficulties for different reasons. It is unlikely that one factor can fully explain the cause of Elimination Disorders. Combinations of factors should be considered. These include: 

Physical factors:  Medical examination should be sought to rule out the physical causes of Enuresis (e.g., smaller bladder size, excessively deep sleep, diabetes, spina bifida, seizure disorders) and Encopresis (e.g., constipation, dehydration, irritable bowel syndrome). 

Psychological factors: Learning and association: Suggestions are made that problems in associating voiding cues (e.g., full bladder, contraction of pelvic muscles) with going to the toilet could instigate primary elimination disorders in some children. Because children learn at different rates, these cues may be learned more slowly for some children than others.

Other than instigating toileting problems, inappropriate learning could maintain these problems. Although they are generally concerned with their toileting problems, children may accidentally learn to associate these problems with positive consequences. They may view improper toileting as instrumental in negotiating their wishes with their parents, securing attention, or assisting them to escape or avoid situations they deem unpleasant (e.g., not going to school or avoidance of chores). 

Stress and anxiety: Many children with elimination disorders, especially the secondary ones, are reported to experience stress. This could include entering a new school or having a new sibling. Additionally, the stress and anxiety could be relevant to elimination itself either in the avoidance (e.g., from negative toileting experience due to painful infection or defecation) or excessive concerns about toileting embarrassment (e.g., anxiety regarding wetting or soiling themselves).
Treatments of Elimination Disorders
Medical Interventions: After physical examination, relevant medical intervention should be attained to alleviate the physical complications of Elimination Disorders. Although medications could help reduce toilet training problems while they are being taken (e.g., laxative softens faeces and reduces pain in defecation), a long-term gain will be obtained only when the medications are used in combination with psychological treatment. 

Psychological Interventions: Psychological treatments of enuresis involve training or re-training children in proper toileting. These treatments vary and will be implemented based on the unique needs of each child. For instance, the Bell-and-Pad Technique could be used to help a child to learn to associate physical cues signalling toileting and the action in doing so. The training of these cues is often reinforced by contingency management in helping the child to associate successful trips to the toilet with desirable rewards. Parenting programs could be implemented as well to help the parents to assist their child go through this process in a non-confronting manner and to increase consistency in their parenting (e.g., reducing accidental rewards of attention or choice avoidance in relation to toileting problems). Finally, psychotherapy could be employed to identify the child’s stress and anxiety and to assist them to effectively regulate unpleasant emotions.
Treatment Outcomes

Combined interventions of medical and psychological treatments have been shown to result in a 90% success rate. Although approximately 15-25% of the children could experience toileting difficulties again after the treatment, the majority are successful in overcoming the problems with follow-up treatment.

Dr Nicole Arthur
BHMS (Ed) B Arts (Psych)(Hons) D Psych Clin MAPS
Clinical Psychologist and Director