1. William T. Dalton III, Ph.D. Assistant Professor & Licensed Psychologist Assistant Director of Clinical Training Department of Psychology East Tennessee State University Diagnosis and Management of Enuresis and Encopresis

2. Disclosure Statement of Financial Interest I, William T. Dalton III, Ph.D., DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. Disclosure Statement of Unapproved/Investigative Use I, William T. Dalton III, Ph.D., DO NOT anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation.

4. Learning Objectives  As a result of participating in this activity, the participant will be able to……  Describe core components of toilet training  Understand diagnosis and management of enuresis  Understand diagnosis and management of encopresis  Objective will be met via……  Lecture  Case studies

5. Overview  Toilet Training 101  Enuresis  Definition  Prevalence  Etiology and Consequences  Assessment/Treatment  Encopresis  Definition  Prevalence  Etiology and Consequences  Assessment/Treatment  Questions

6. Get Ready!  Pee  Poop

7. Toilet Training 101  Toilet Training  Many problems can be avoided by waiting longer before beginning  Appropriate age to begin is 30 months or more (2 ½ years)  May work on some components before such as dressing, undressing, and vocabulary, as well as general behavioral compliance  Child should also be producing consistent, soft formed stools as a prerequisite

8. Toilet Training 101  Physical Considerations  Comfortable, convenient place for practice (child-sized potty chair)  Important for feet to touch floor, offering stability as well as place to put feet to push for leverage when trying to pass a stool  If choose regular toilet consider two small steps in front of toilet

9. Toilet Training 101  Readiness for Toilet Training  Major milestone in physical and social development that is often achieved during the day by 36 months although accidents may continue through 5 years  Readiness Criteria Bladder control (should empty completely and stay dry) Physical readiness (fine- and gross-motor coordination) Instructional readiness (ability to follow directions)  See Handout 8.1*

10. Toilet Training 101  Methods  Brazelton’s “Indirect” Method Around 18 months introduced to chair and invited to sit clothed 1-2 weeks later taken to potty chair to sit with diapers off Next taken to chair once daily to empty soiled diapers Finally chair is placed in child’s room or play area and child does not wear diapers with instruction to use potty if wishes After cooperation in preceding phases child is dressed in training pants and encouraged to use potty 80% trained by age 3 with average of 28 months for day training and 33 months for night training

11. Toilet Training 101  Methods  Azrin and Foxx’s “One-Day” Method Toilet Training in Less Than a Day Components Practice and reinforcement in dressing skills Immediacy of reinforcement for correct toileting Required practice in toilet approach after accidents Learning by imitation Probably unrealistic to suggest to parents they can train in one day but rather around the time turning age 3…

12. Toilet Training 101  Toileting Refusal  May be difficult to determine why child refuses to have bowel movement in toilet but will in diaper…comfort, convenience, etc.  Toileting Resistance (without constipation) Child may be reminded or lectured too much  Toileting Refusal Due to Constipation Size and consistency of stools Declare moratorium on training 1 month Instead, focus on diet and medications and consider focusing on general compliance

13. Quiz: What’s Missing?

14. Enuresis  Definition  Repeated voiding of urine into bed or clothes  Involuntary or intentional  Clinically significant (twice per week for 3 months or impaired functioning)  Chronological or developmental age of at least 5 years  Not due to substance or general medical condition  Nocturnal/Diurnal

15. Enuresis  Prevalence  25% of boys and 15% of girls at age 6  8% of boys and 4% of girls at age 12  Relatively benign condition and often resolves even without treatment  15% spontaneous cure rate  Consistent across races  Diminished social resources may be associated with increased prevalence

16. Enuresis  Etiology  Biological Variables Genetics Developmental Delay?  Emotional Variables Early theories (e.g., “weeping through the bladder”, sexual conflict) Significant emotional disturbance has not been found in majority of children with diagnosis  Etiology (Cont’d)  Learning Variables Most accepted view Problem in learning At birth process of urination governed by reflex action Adults learn to delay reflexive behavior for long periods of time Children during development are attempting to master learning tasks of controlling a reflexive behavior and some have difficulty

17. Enuresis  Health and Psychological Consequences  Could be marker for medical conditions such as urinary tract infections  Psychosocial consequences result from shaming, blaming and characterological attributions that are directed to incontinent children in addition to increased risk of child abuse secondary to incontinence  Evidence-based Assessment  No widely used tools  Most research using instruments that incorporate items into larger constellation of items on psychosocial issues  Dysfunctional Voiding Scoring System assesses enuresis and other co-morbid voiding and/or elimination symptoms  Domains of interest include wet or dry days or nights and size of urine spot  See Handout 8.10* and Exhibit 6.2**

18. Enuresis  Evidence-based Interventions  Bell-and-Pad or Urine-Alarm Training treatment success is higher and relapse rate lower than any other method See Exhibit 6.3** and Table 6.1**

19. Enuresis  Evidence-based Interventions (Cont’d)  Multiple Intervention Package Programs Dry-Bed Training Urine alarm, positive practice, nighttime awakenings, retention control training, and positive reinforcement See Handout 8.11* and Exhibit 6.4** Full-Spectrum Home Training Urine alarm, retention control training, and overlearning  Components Positive Practice See Exhibit 6.5** Nighttime Awakenings Retention Control Overlearning

20. Enuresis  Medications  Imipramine  Desmopressing Acetate  Oxybutynin Chloride  Other Treatment Approaches  Hypnosis  Sphincter exercises  Restriction of fluids before bed

21. Quiz: What should you do?  Suzy, age 4, presents with her parents who are concerned that she is not continent for urine. They have been told that she will not be able to begin kindergarten until she is toilet trained. What should you do in terms of some first steps ?

22. Encopresis  Definition  Repeated passage of feces into inappropriate places  Involuntary or intentional  At least once a month for at least 3 months  Chronological or developmental age of at least 4 years  Not due to substance or general medical condition except constipation  With/Without Constipation and Overflow Incontinence

23. Encopresis  Prevalence  Ranges from approximately 4% of 4-year-olds and 1.6% of 10-year-olds children, affecting boys 3 to 6 times more often than girls  As many as 95% of children referred for treatment present with functional constipation  No or limited data showing associations with intelligence, SES, ethnicity, family size, child position in family or parental age, emotional adjustment, and child abuse  Population studies scarce

24. Encopresis  Etiology  Biological Variables Genetics Developmental Delay? Hirschsprung’s disease  Emotional Variables Early theories assumed psychodynamic etiology (e.g., unconsious conflict, personality profiles)  Etiology (Cont’d)  Learning Variables Most useful view considers types Manipulative Stress-induced Constipation (80-95% of cases) Manipulative soiling follows reinforcement model Chronic diarrhea and loose bowels Chronic Constipation Diet Toilet habits/Withholding School bathroom conditions

25. Encopresis

26.  Health and Psychological Consequences  Most serious/common involves urinary tract infections from contamination of urinary tract with feces from child’s underwear  Most serious social consequence is teasing and ridicule from peers, classmates, friends, and siblings  Evidence-based Assessment  One of the available general parent and teacher rating scales (BASC, CBCL, Connors CBRS) to identify comorbidities such as ODD and ADHD which may interfere with parent’s ability to implement treatment recommendations  See Handouts 8.5* and 8.7*, and Exhibits 5.2** and 5.4**

27. Encopresis

28.  Evidence-based Interventions  For “Retentive” Encopresis Medical-Behavioral Treatment Uses of medication (oral or rectal) to address constipation Maintenance of regular and healthy bowel functioning and preventing constipation Diet management including reduction of dairy products when indicated Much success reported when dietary and exercise included Treatment preventing or postponing reappearance of constipation necessary  Evidence-based Interventions (Cont’d)  Other Behavioral Targets for “Retentive and NonRetentive” Appropriate and immediate response to urge to defecate with trips to toilet Resolution of toilet avoidance/fear Appropriate toilet-sitting and defecation dynamics Ensure enough time on toilet for evacuation Implement toilet sitting schedule 10-30 minutes after breakfast and dinner

30. Encopresis  Other Treatment Approaches  Biofeedback no better than Medical-Behavioral  For “Manipulative Soiling” Behavioral and family therapy Coping and communication skills emphasized Reward appropriate behaviors and do not reinforce soiling behavior  Other Treatment Approaches (Cont’d)  For “Chronic Diarrhea or Irritable Bowel Syndrome” Stress reduction and learning effective coping skills Systematic desensitization and hypnosis Relaxation training, stress inoculation training, assertiveness training, general stress management Supportive psychotherapy and antidiarrheal medications

31. Quiz: What should you collect?  Tom, age 6, presents with his parents to address his stool incontinence. He has a long history of withholding and constipation with fecal leakage daily. His parents report that he once used the toilet but had a large, hard stool causing pain and now avoids the bathroom. What data might you collect via a record chart?

32. Questions?

33. References  Campbell, L. K., Cox, D. J., Borowitz, S. M. (2009). Chapter 32: Elimination disorders: Enuresis and encopresis. In M. C. Roberts & R. G. Steele (Eds.), Handbook of Pediatric Psychology (Fourth Edition; pp. 481-490). New York: The Guilford Press.  *Christophersen, E. R. (1994). Pediatric compliance: A guide for the primary care physician. New York: Plenum Medical Book Company.  **Christophersen, E. R., & Mortweet, S. L. (2001). Treatments that work with children: Empirically supported strategies for managing childhood problems. Washington, DC: American Psychological Association.  Society of Pediatric Psychology (Division 54) American Psychological Association. Evidence-based Practice Resources (Fact Sheets: Enuresis and Encopresis). Retrieved from http://www.apadivisions.org/division- 54/evidence-based/fact-sheets.aspxhttp://www.apadivisions.org/division- 54/evidence-based/fact-sheets.aspx  Walker, C. E. (2003). Chapter 32: Elimination disorders: Enuresis and encopresis. In M. C. Roberts (Ed.), Handbook of Pediatric Psychology (Third Edition; pp. 544-560). New York: The Guilford Press.