Toileting: The Assessment and Treatment of Enuresis and Encopresis
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Transcript Toileting: The Assessment and Treatment of Enuresis and Encopresis
Toileting: The Assessment and
Treatment of Enuresis and
Encopresis
Emily D. Warnes, Ph.D.
EDPS 951
Enuresis: Definition
DSM IV definition:
“Repeated voiding of urine into bed or
clothes, whether involuntary or
intentional” (American Psychiatric
Association, 2000, p. 121).
Enuresis: Diagnostic Criteria
307.6 Enuresis
Repeated voiding of urine into bed or clothes
Clinically significant
Twice per week for at least 3 consecutive months
Impairment in daily functioning (e.g., social academic)
Chronological Age: 5 years (or developmental
equivalent)
Behavior is not due exclusively to the direct
physiological effect of the following:
Substance (e.g., diuretic)
General Medical Condition (e.g., diabetes. Seizure disorder)
Enuresis: Definition
Enuresis Types:
Diurnal
Voids occurring during the daytime
Nocturnal
Voids occurring during the nighttime
Enuresis: Prevalence
Incidence of Nocturnal Enuresis
40
35
30
30
Percentage (%)
25
20
15
10
10
5
3
1
0
4
6
Age in Years
12
18
Enuresis: Prevalence
Who Experiences Nocturnal Enuresis?
5-7 million American children over age 5
15% spontaneously remit per year
Males
Females
Estimates range up to 25% at age 6 and 8% at age 12
Estimates range up to 15% at age 6 and 4% at age 12
Approximately 15% to 20% also experience diurnal
enuresis
Enuresis: Etiology
Familial Factors: Incident Rates
77% in children who have both maternal and
paternal positive history for NE
44%, one parent with positive history of NE
15% , no parental history of NE
Enuresis: Etiology
Sleep Factors
Parents of children with NE report remarkably
heavy sleep
Sleep EEG research suggests enuretic
episodes indiscriminately transpire across the
night
Sleep patterns parallel between children with
and without enuresis
Enuresis: Etiology
Biological Factors
Mean bone growth and height less developed
among children with enuresis
Small bladder capacity
Research suggests bladder capacity remains the
same during day and night
Increased nocturnal urine output
Differences in production of the antidiuretic
horomone (ADH)
Enuresis: Etiology
Bio-Behavioral Factors
Integration of biological factors and
behavioral learning principles
Assessment
Treatment
Enuresis: Assessment
Medical Assessment
Rule out significant medical condition
Most often already ruled out by the time you
see the kid
Behavioral Assessment
Assess general behavior using a broad-band
rating scale (e.g., CBCL or BASC)
Enuresis: Assessment
Behavioral Assessment: Interview
Behavioral or developmental problems
Medical conditions
History and current status of problem
Family history
Potty training history
Enuresis: Assessment
Behavioral Assessment: Interview
Environmental contributors (e.g., when, how
much fluid intake, proximity to b-room, sleep
routine and arrangements)
Consequences (e.g., how do parents handle
it, how does the child react)
Child’s feelings and motivation to treat
Enuresis: Assessment
Behavioral Assessment: Recording Data
Provide Chart for recording voids
Assess time of night, number of voids, size of
void, reaction
Enuresis: Treatment
Pharmacological
Imipramine (Trofanil)
Tricyclic antidepressant
Once medication discontinued, bedwetting
resumes
Relapse rate varies from 60% to 90%
Duration of treatment varies without consensus
Enuresis: Treatment
Pharmacological
Desmopressin Acetate (DDAVP)
Analogue of Vasopressin (ADH)
Supports urine concentration
Decreases urine volume during nighttime
Research findings yield mixed outcomes
Increased number of dry nights
Dryness may not maintain once terminate DDAVP
Relapse rate varies from 50% to 95%
Enuresis: Treatment
Behavioral
Moisture Alarm (Bell and Pad)
Classical Conditioning
Full bladder
Voids
Alarm sounds
Awakenings
Operant Conditioning
Avoid aversive conditions during night (e.g., waking up
to a wet bed, cleaning up procedures, changing bed
linens)
Enuresis: Treatment
Moisture Alarm
Generally achieve dry nights within 2- 4
months
Research suggests up to 70% successful
outcomes
High Response Effort
Enuresis: Treatment
Arousal Training –Focus on R+ getting up
Awakens
Turns off alarm
Attends the restroom for toilet sit
Reattach enuresis alarm
Encopresis
Encopresis: Definition
Involuntary loss of formed, semiformed,
or liquid stool in inappropriate places, such
as underwear, in children older than age 4
Encopresis: Diagnostic Criteria
Encopresis
Repeated passage of feces into inappropriate places
(e.g., clothing or floor)
Clinically significant
Once per month for at least 3 months
Chronological Age: 4 years (or developmental
equivalent)
Behavior is not due exclusively to the direct
physiological effect of the following:
Substance (e.g., laxatives)
General Medical Condition except constipation
Encopresis: Diagnostic Criteria
Encopresis
Code as follows:
797.6 With Constipation and Overflow
Incontinence
307.7 Without Constipation and Overflow
Incontinence
Encopresis: Prevalence
1-2% of the child population
Boys are 3-6 times more likely to have it
than girls
Mean onset is 7 years old
95% of children referred for treatment of
encopresis have constipation
Encopresis: Etiology
Little support for genetic basis for the
disorder
Little support for emotional and behavioral
problems associated with encopresis
More a problem of dysfunction of the
bowel
Encopresis: Etiology
Rule Out Hirschsprung Disease
Absence of ganglion cells and normal
peristaltic waves in one segment of the bowel
Develop a megacolon
Risk for impaction
Seepage of liquid stool
Encopresis: Assessment
Medical Assessment
Rule out Hirschprung’s
Any constipating medications
Diet (i.e., fiber intake, water)
Encopresis: Assessment
Behavioral Assessment: Interview
Toilet training history
Any behavioral or emotional problems
Recent stressful precipitating events
Current status of toileting habits and bowel
movements
Encopresis: Assessment
Behavioral Assessment: Interview
Environmental contributors (e.g., routine, diet
and exercise)
Consequences (e.g., parental reactions, child
reactions)
Child motivation for treatment
Encopresis: Assessment
Behavioral Assessment: Recording Data
Provide Chart for recording bowel movements
Assess place, number of voids, size and
consistency of void, reaction
Record fiber intake and exercise
Encopresis: Treatment
Combination of medical and behavioral
treatment the most effective approach
Medical Treatment
Clean out the bowel
Enemas
Laxatives
Increase fiber and exercise
Ensure regular bowel movements
Encopresis: Treatment
Behavioral Treatment
Scheduled toilet sits
After meals or suppositories/laxatives
Make relaxing
Keep brief (e.g., 5-10 minutes)
Reinforcers for sits and then poops in the
toilet
Minimize reaction to accidents