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