Elimination disorders occurs when children who are otherwise old enough to eliminate waste appropriately repeatedly void feces or urine in inappropriate places or at inappropriate times. The two disorders that fall under this category are Enuresis (for urine) and Encopresis (for feces).

Although it is not uncommon for
young children to have
occasional “accidents,” there
may be a problem if this behavior
occurs repeatedly for longer than
three months, particularly in children older than five years.

The diagnosis of enuresis is established based on it occurring at least two times per week for at least three consecutive months and for encopresis occurring once per month for at least three consecutive months. The child has to be at least four years and above for a diagnosis of both disorders to be considered. Both conditions have a good prognosis with high rates of spontaneous remission. These disorders can be organic meaning occurring due to natural physiological issues, socio-emotional causes and sometimes comorbid with psychological disorders.

NORMAL DEVELOPMENT FOR CONTINENCE

Before I explain enuresis and encopresis in detail, it is important to understand how continence is achieved in development. Babies eliminate both urine and feces at any time and they have no control of it, as they grow older you will notice that from around as early as six months some babies will stop passing feces at night and will only wake up in the morning with a wet nappy; that is an indication of maturation. The system prepares itself for continence through this maturation process and it is one of the major factors that affect continence. Children will achieve continence at different times in the first four years of life and this is dependent on maturation and training. During the toddler phase a child usually becomes interested in mastering elimination. Most children will achieve bowel and bladder continence by age four and females achieve continence earlier than males

Acquiring continence usually proceeds in the following order:

1. Night time bowel – this happens earlier before the age one.
2. Day time bowel – bowel movements reduce in babies and in some babies you are able to pick up a pattern of when they happen and the child has awareness of what is happening.

c. Daytime bladder – toddlers start ‘feeling’ the urine and sometimes are bothered by their soiled nappy and at this stage toilet training redirects the behavior to eliminate in the toilet instead of on self.

d. Night time bladder – achieving day time bladder control does not mean night time is automatic, for some children it is automatic but for some night time training is required.

ENURESIS

Enuresis is more commonly known as bed-wetting which only refers to the night time bladder incontinence however there are three types of enuresis and these are:

•  Nocturnal enuresis – Nocturnal enuresis is involuntary urination that happens at night while sleeping, after the age when a person should be able to control his or her bladder. It is the most common type.
•  Diurnal/day time enuresis occurs in the absence of nocturnal enuresis and is commonly referred to as urinary incontinence. It can be voluntary or involuntary.
•  The nocturnal-and-diurnal subtype is a combination of the first two.
  Nocturnal enuresis is more common in males and diurnal incontinence is more common in females. It is further classified as either primary or secondary.

•  Primary enuresis indicates that a child has never accomplished continence through the night. This type is mostly due to maturational /or physiological delays, medical causes are also possible.
•  Secondary enuresis is when a child achieved continence for at least six consecutive months but began wetting themselves again. This may be caused by psycho-social factors or an underlying medical condition. When a child achieves bladder control, the nerves in the bladder wall send a message to the brain when the bladder is full. The brain then sends a message back to the bladder to keep it from automatically emptying until the person is ready to go to the bathroom.

WHAT CAUSES ENURESIS

•  Hormonal problems. – A hormone called antidiuretic hormone (ADH) causes the body to make less pee at night. If it is not produced or not enough it means the body may make too much urine while sleeping.
•  Bladder problems – Too many muscle spasms can prevent the bladder from holding a normal amount of pee and also having relatively small bladders that can’t hold a lot of urine.
•  Genetics – Having a parent who had enuresis at about the same age especially the father presents a 70% chance of a child experiencing the same.
•  Sleep problems – Some children continue to sleep deeply that they don’t wake up when they need to pee and some suffer from sleep disorders like sleep terror disorder.
•  Medical conditions – Medical conditions that can trigger secondary enuresis include diabetes, urinary tract abnormalities (problems with the structure of a person’s urinary tract), constipation, and urinary tract infections (UTIs). Enuresis may occur during treatment with antipsychotic medications, diuretics, or other medications that may induce incontinence.

•  Psychological problems – Some psychological disorders occur together (comorbid) with enuresis for example in children with ADHD, children with anxiety disorders and children on the Autism Spectrum. Environmental factors are also believed to be linked to enuresis for example divorce of parents, abuse etc.
•  Poor toilet training – Sometimes children are forced into toilet training before they are ready and maturation has not been reached creating negativity to the elimination process. ENCOPRESIS Encopresis or fecal incontinence is the repeated passing of stool into clothing or inappropriate places, whether involuntary or intentional. There are two basic categories of encopresis:

•  Primary encopresis – refers to children who have never attained bowel control.
•  Secondary encopresis – refers to soiling oneself after successfully attaining bowel control usually brought upon by entering a stressful environment such as family conflict. Medical causes are also a possibility. Encopresis has two main subtypes: Without constipation and overflow incontinence subtype – feces are likely to be of normal form and consistency, and soiling is intermittent. Soiling without constipation appears to be less common than soiling with constipation. With constipation and overflow incontinence subtype – Feces are mostly poorly formed, and leakage can be infrequent to continuous, occurring mostly during the day and rarely during sleep. Only part of the feces is passed during toileting. Boys with encopresis outnumber girls by a ratio of six to one, the reasons for this greater prevalence among males is not known

WHAT CAUSES ENCOPRESIS

•  Constipation – Typically it happens when compacted stool collects in the colon and rectum; the colon becomes too full and liquid stool leaks around the retained stool. For elimination to occur (or not) there is an interaction between physiological functioning and behavioral responses. In brief, increased time between bowel movements, influenced by multiple factors such as diet or reluctance to use the toilet, results in a fecal compaction that leads to potentially painful defecation. As a result, children show toileting resistance that further increases the time between bowel movements, leading to overflow incontinence
•  Inadequate, inconsistent toilet training – Premature, difficult or conflict-filled toilet training may result in poor elimination.

•  Psychosocial stress – for example starting school, the birth of a sibling or the death of a loved one may be predisposing factors.
•  Medications – Some cough medications can cause constipation.
•  It is rarely caused by an anatomic abnormality or disease but a medical exam is important just to rule it out.

TREATMENT

It is crucial for parents to understand that incontinence rarely happens without an explanation whether medical or psycho-social. Many times parents and caregivers criticize or scold a child over the lack of toileting skills only to find out later that the problem was beyond the child’s control.

Seek medical evaluation and if a physical problem is ruled out then the parents will need to address the behavioral component of elimination disorders.

There are various categories of treatment options that are available to children and families but this depends on the underlying causes (etiology) hence it is important to seek medical evaluation first. I am going to just give some educational points that are important regardless of which treatment option is administered.

Most of the interventions fall into these two broad categories

1. Bio-medical interventions and management
2. Psycho-therapeutic Interventions

These are some of the educational points that a family should be aware of in order to help in the treatment of an elimination disorder (mostly for enuresis):

•  Review and correct parental expectations – children are not the same and what worked for one child on toilet training might not work for the other.
•  Wait until the child is ready for toilet training – some children will show signs of maturation by telling you when they want to eliminate or communicating their discomfort of soiling themselves.
•  Ensuring there is no teasing/shame given for failures. Remind a child that it isn’t their fault.
•  Do not punish the child.

It is crucial for parents to understand that incontinence rarely happens without an explanation whether medical or psycho-social. Many times parents and caregivers criticize or scold a child over the lack of toileting skills only to find out later that the problem was beyond the child’s control.

Seek medical evaluation and if a physical problem is ruled out then the parents will need to address the behavioral component of elimination disorders.

There are various categories of treatment options that are available to children and families but this depends on the underlying

•  Achieving continence takes time – learn patience as a parent, regression is a possibility after successful training.
•  Involve teachers who may discretely remind a child to take bathroom breaks.
•  Limit Nighttime fluid intake- all fluid should be withheld within 1 hour of before bed
•  Dairy products should be stopped 4 hours before bed as they have a potential to cause osmotic diuresis
•  Encourage urinating before bed to empty the bladder.
•  Leave a night light on in the passage or in the bathroom – this helps a child not to be afraid to go to the bathroom by themselves.
•  Help the child clean soiled linen do not make it their task as this can be interpreted as punishment.
•  Girls can benefit from being reminded to wipe from front to back to prevent UTIs

Talent Adamson

Behaviour Therapist

BA (Health and Social Services) Applied Psychology, BA Hon (HSS) Psychological Counselling – (UNISA)