Diagnosis and Management of
Enuresis and Encopresis
William T. Dalton III, Ph.D.
Assistant Professor & Licensed Psychologist
Assistant Director of Clinical Training
Department of Psychology
East Tennessee State University
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.
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.
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
Overview


Toilet Training 101
Enuresis
Definition
 Prevalence
 Etiology and Consequences
 Assessment/Treatment


Encopresis
Definition
 Prevalence
 Etiology and Consequences
 Assessment/Treatment


Questions
Get Ready!

Pee

Poop
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
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
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*
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
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…
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
Quiz: What’s Missing?
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
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
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
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**
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**
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
Enuresis

Medications




Imipramine
Desmopressing Acetate
Oxybutynin Chloride
Other Treatment
Approaches



Hypnosis
Sphincter exercises
Restriction of fluids before
bed
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 ?
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
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
Encopresis

Etiology

Biological Variables




Genetics
Developmental Delay?
Hirschsprung’s disease

Etiology (Cont’d)

Learning Variables



Emotional Variables

Early theories assumed
psychodynamic etiology (e.g.,
unconsious conflict, personality
profiles)
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
Encopresis
Encopresis

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**
Encopresis
Encopresis

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
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
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?
Questions?
References
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



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/division54/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.