Potty ProblemsWetting and Soiling

(Enuresis and Encopresis)

Presented by: Amanda Wagley

Formal DefinitionsDSM IVEnuresis, 307.6

A.     Repeated voiding of urine into bed or clothes (whether involuntary or intentional).

B.   The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupa tional), or other important areas of functioning. 

C.   Chronological age is at least 5 years (or equivalent developmental level). 

D.  The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition ( e.g., diabetes, spina bifida, a seizure disorder)

Formal Definitions Cont.DSMIVEncopresis 787.6, 307.7 (w/or w/o constipation and overflow inconsistence)A.      Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional.

B.       At least one such event a month for at least 3 months.

C.       Chronological age is at least 4 years (or equivalent developmental level).

D.      The behavior is 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.

Who Has it?Mostly 5-7 year olds

More common in boys (2:1)Can affect girls and older children too

GeneticsEncopresis is not as common as enuresis

Encopresis without constipation is more rareCan be a sign of abuse (sexual or physical)

(Shapira & Dahlen, 2010) & (Coehlo, 2011)

Types of Enuresis Primary

Occurs 2-3 times per weekSecondary

Occurs when a child starts wetting after several months or years without an “episode”

Usually brought on by additional stressors Divorce New Home New Baby

NocturnalOccurs only at night Most common form of Enuresis is primary nocturnal

(aacap.org, 2004)

Could it be something else?Urinary tract infectionDiabetes (Enuresis)Sickle Cell (Enuresis)SeizuresSpina bifidaConstipationPain passing stool (Encopresis)

(Geroski & Rogers, 1998)

Causes/CharacteristicsEnuresis Encopresis Sleep arousal difficulties Production of large amounts of urine Bladder dysfunction (overactive or

small bladder) Developmental delays Low level of ADH hormone Learning difficulties Behavioral problems Family problems (specifically

parental separation) (Norfolk & Wootton, 2011)

Painful or unpleasant bowel movement

Chronic constipationLow muscle toneSlow intestinal motilityAtypical attention spanFear from flushing toiletSexual abuseLack of exercise and/or waterDiets high in fats and sugarOCD (Coehlo, 2011)

Common ComorbiditiesADHD DepressionAnxiety DisordersODD(Akça, Aysev, & Aycan, 2011)Select Mutism (Wong, 2010)Sleep Disorder(aacap.org)

What Can We Do? Enuresis DO NOT PUNISH! Bladder Stretching Pharmacology

Desmopressin Synthetic analog of ADH

Anti-depressants (Tofranil) Reduce irritability of the bladder muscles

Both have about 50%-80% success rate with about 60% -90% relapse. Behavior Modification

Cleanliness Exercises Reward Interventions Limit Fluid intake

Enuresis Alarm Urine sensitive pad connected to an alarm

(Shapira & Dahlen, 2010)

Enuresis Alarm

What Can We Do? Encopresis DO NOT PUNISH! Pharmacology

Stool Softeners Laxatives Suppositories

Bowel Training Teaches the child how to know when they need to use the restroom

Behavior Management Punishment does not work Maintain regular bathroom routines Cleanliness exercises Positive reinforcement

Nutritional Changes Add fiber and bran Decrease foods high in fat and sugar

Family Support Self esteem Depression (Coehlo, 2011)

If Left UntreatedMost will grow out if it on their ownCan lead to:

DepressionLow self-esteemNegative Self-imageNegative affects on Peer relationshipsCan lead to behavioral and emotional problems

The psychological and emotional effects can cause more damage than the disorder itself.

(Shapira & Dahlen, 2010), (Norfolk & Wootton, 2011)

Steps for School CounselorsNormalize the situation for the child

Let them know they are not alone.Educate parents Help the parents and the child cope Provide suggestions for further reading Suggest a medical evaluation by a pediatricianRefer to a pediatric counselor

(Erford, 2011)

Helping ProfessionalsCounselors

Focus on “normalizing” Overcome embarrassment

School NursesPediatricians & Pediatric Nurses

Rule out underlying medical causesPossibility of an immature bladder or bladder dysfunctionWrite prescriptions in needed

Specialist Enuresis Nurses

Further ReadingChildhood Encopresis

and Enuresis: Causes and Therapy

Overcoming Bladder & Bowel Problems in Children

Seven Steps to Nighttime Dryness: A Practical Guide for Parents of Children with Bedwetting

Reading for KidsEveryone PoopsClouds and Clocks: A

Story for Children Who Soil

Sammy the Elephant & Mr. Camel: A Story to Help Children Overcome Bedwetting

Zumar the Alien: An Interplanetary Tale of Bedwetting

ResourcesUS Department of Health and Human Services

National Kidney & Urologic Diseaseshttp://kidney.niddk.nih.gov/KUDiseases/pubs/bedwetting_EZ/index.aspx

CHKD Treatment Centerhttp://www.chkd.org/HealthLibrary/Content.aspx?pageid=P01992http://www.chkd.org/HealthLibrary/content.aspx?pageid=P02206

Education and Resources for Improving Childhood Continence (ERIC) http://www.eric.org.uk/

www.ucanpooptoo.comCounselors/Therapists in Hampton Roads

http://therapists.psychologytoday.com/rms/name/Pat_Davis_LPC,LMFT,NBCC_Virginia+Beach_Virginia_85097

Resources Cont.The Bedwetting Store

http://bedwettingstore.com/?gclid=CMjr5uvlj64CFSU0QgodUmztBg

Enuresis Treatment Centerwww.drybed.com

American Academy of Pediatricswww.aap.org

American Urological Association Foundationwww.auafoundation.org

National Association for Continencewww.nafc.org

References American Academy of Child and Adolescent Psychiatry. (December 2011). Facts for families: bedwetting.

Retrieved from www.aacap.org. American Academy of Child and Adolescent Psychiatry. (November 2004). Facts for families: problems with

soiling and bowel control. Retrieved from www.aacap.org. Akça, Ö., Aysev, A., & Aycan, İ. (2011). Familial features and comorbid psychiatric disorders in children

with encopresis. Bulletin of Clinical Psychopharmacology, 21(4), 345- 352. American Psychiatric Association. (2004). Diagnostic and statistical manual of mental disorders (4th ed.,

text rev.). Washington, D.C.: Author. Coehlo, D. (2011). Encopresis: a medical and family approach. Pediatric Nursing, 7(3),107- 112. Erford,

B. (2011). Transforming the school counseling profession. Upper Saddle River, New Jersey: Pearson Education, Inc.

Geroski, A. & Rodgers, K. (1998). Collaborative assessment and treatment of children with enuresis and encopresis. Professional School Counseling, 2(2). 128.

Norfolk, S. & Wootton, J. (2011). Supporting children with nocturnal enuresis. British Journal of School Nursing, 6(5), 225-228.

Shapira, B. & Dahlen, P. (2010). Therapeutic treatment protocol for enuresis using an enuresis alarm. Journal of Counseling &Development, 88, 246-252.

Wong, P. (2010). Selective mutism: a review of etiology, comorbidities, and treatment. Psychiatry (1550-5952), 7(3), 23-31.