1. Toileting: The Assessment and Treatment of Enuresis and Encopresis Emily D. Warnes, Ph.D. EDPS 951

2. Enuresis: Definition DSM IV definition: DSM IV definition: “Repeated voiding of urine into bed or clothes, whether involuntary or intentional” (American Psychiatric Association, 2000, p. 121).

3. Enuresis: Diagnostic Criteria 307.6 Enuresis 307.6 Enuresis Repeated voiding of urine into bed or clothes Repeated voiding of urine into bed or clothes Clinically significant Clinically significant Twice per week for at least 3 consecutive months Twice per week for at least 3 consecutive months Impairment in daily functioning (e.g., social academic) Impairment in daily functioning (e.g., social academic) Chronological Age: 5 years (or developmental equivalent) Chronological Age: 5 years (or developmental equivalent) Behavior is not due exclusively to the direct physiological effect of the following: Behavior is not due exclusively to the direct physiological effect of the following: Substance (e.g., diuretic) Substance (e.g., diuretic) General Medical Condition (e.g., diabetes. Seizure disorder) General Medical Condition (e.g., diabetes. Seizure disorder)

4. Enuresis: Definition Enuresis Types: Enuresis Types: Diurnal Diurnal Voids occurring during the daytime Voids occurring during the daytime Nocturnal Nocturnal Voids occurring during the nighttime Voids occurring during the nighttime

5. Enuresis: Prevalence

6. Who Experiences Nocturnal Enuresis? Who Experiences Nocturnal Enuresis? 5-7 million American children over age 5 5-7 million American children over age 5 15% spontaneously remit per year 15% spontaneously remit per year Males Males Estimates range up to 25% at age 6 and 8% at age 12 Estimates range up to 25% at age 6 and 8% at age 12 Females Females Estimates range up to 15% at age 6 and 4% at age 12 Estimates range up to 15% at age 6 and 4% at age 12 Approximately 15% to 20% also experience diurnal enuresis Approximately 15% to 20% also experience diurnal enuresis

7. Enuresis: Etiology Familial Factors: Incident Rates Familial Factors: Incident Rates 77% in children who have both maternal and paternal positive history for NE 77% in children who have both maternal and paternal positive history for NE 44%, one parent with positive history of NE 44%, one parent with positive history of NE 15%, no parental history of NE 15%, no parental history of NE

8. Enuresis: Etiology Sleep Factors Sleep Factors Parents of children with NE report remarkably heavy sleep Parents of children with NE report remarkably heavy sleep Sleep EEG research suggests enuretic episodes indiscriminately transpire across the night Sleep EEG research suggests enuretic episodes indiscriminately transpire across the night Sleep patterns parallel between children with and without enuresis Sleep patterns parallel between children with and without enuresis

9. Enuresis: Etiology Biological Factors Biological Factors Mean bone growth and height less developed among children with enuresis Mean bone growth and height less developed among children with enuresis Small bladder capacity Small bladder capacity Research suggests bladder capacity remains the same during day and night Research suggests bladder capacity remains the same during day and night Increased nocturnal urine output Increased nocturnal urine output Differences in production of the antidiuretic horomone (ADH) Differences in production of the antidiuretic horomone (ADH)

10. Enuresis: Etiology Bio-Behavioral Factors Bio-Behavioral Factors Integration of biological factors and behavioral learning principles Integration of biological factors and behavioral learning principles Assessment Assessment Treatment Treatment

11. Enuresis: Assessment Medical Assessment Medical Assessment Rule out significant medical condition Rule out significant medical condition Most often already ruled out by the time you see the kid Most often already ruled out by the time you see the kid Behavioral Assessment Behavioral Assessment Assess general behavior using a broad-band rating scale (e.g., CBCL or BASC) Assess general behavior using a broad-band rating scale (e.g., CBCL or BASC)

12. Enuresis: Assessment Behavioral Assessment: Interview Behavioral Assessment: Interview Behavioral or developmental problems Behavioral or developmental problems Medical conditions Medical conditions History and current status of problem History and current status of problem Family history Family history Potty training history Potty training history

13. Enuresis: Assessment Behavioral Assessment: Interview Behavioral Assessment: Interview Environmental contributors (e.g., when, how much fluid intake, proximity to b-room, sleep routine and arrangements) 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) Consequences (e.g., how do parents handle it, how does the child react) Child’s feelings and motivation to treat Child’s feelings and motivation to treat

14. Enuresis: Assessment Behavioral Assessment: Recording Data Behavioral Assessment: Recording Data Provide Chart for recording voids Provide Chart for recording voids Assess time of night, number of voids, size of void, reaction Assess time of night, number of voids, size of void, reaction

15. Enuresis: Treatment Pharmacological Pharmacological Imipramine (Trofanil) Imipramine (Trofanil) Tricyclic antidepressant Tricyclic antidepressant Once medication discontinued, bedwetting resumes Once medication discontinued, bedwetting resumes Relapse rate varies from 60% to 90% Relapse rate varies from 60% to 90% Duration of treatment varies without consensus Duration of treatment varies without consensus

16. Enuresis: Treatment Pharmacological Pharmacological Desmopressin Acetate (DDAVP) Desmopressin Acetate (DDAVP) Analogue of Vasopressin (ADH) Analogue of Vasopressin (ADH) Supports urine concentration Supports urine concentration Decreases urine volume during nighttime Decreases urine volume during nighttime Research findings yield mixed outcomes Research findings yield mixed outcomes Increased number of dry nights Increased number of dry nights Dryness may not maintain once terminate DDAVP Dryness may not maintain once terminate DDAVP Relapse rate varies from 50% to 95% Relapse rate varies from 50% to 95%

17. Enuresis: Treatment Behavioral Behavioral Moisture Alarm (Bell and Pad) Moisture Alarm (Bell and Pad) Classical Conditioning Classical Conditioning Full bladder Full bladder Voids Voids Alarm sounds Alarm sounds Awakenings Awakenings Operant Conditioning Operant Conditioning Avoid aversive conditions during night (e.g., waking up to a wet bed, cleaning up procedures, changing bed linens) Avoid aversive conditions during night (e.g., waking up to a wet bed, cleaning up procedures, changing bed linens)

18. Enuresis: Treatment Moisture Alarm Moisture Alarm Generally achieve dry nights within 2- 4 months Generally achieve dry nights within 2- 4 months Research suggests up to 70% successful outcomes Research suggests up to 70% successful outcomes High Response Effort High Response Effort

19. Enuresis: Treatment Arousal Training –Focus on R+ getting up Arousal Training –Focus on R+ getting up Awakens Awakens Turns off alarm Turns off alarm Attends the restroom for toilet sit Attends the restroom for toilet sit Reattach enuresis alarm Reattach enuresis alarm

20. Encopresis

21. Encopresis: Definition Involuntary loss of formed, semiformed, or liquid stool in inappropriate places, such as underwear, in children older than age 4 Involuntary loss of formed, semiformed, or liquid stool in inappropriate places, such as underwear, in children older than age 4

22. Encopresis: Diagnostic Criteria Encopresis Encopresis Repeated passage of feces into inappropriate places (e.g., clothing or floor) Repeated passage of feces into inappropriate places (e.g., clothing or floor) Clinically significant Clinically significant Once per month for at least 3 months Once per month for at least 3 months Chronological Age: 4 years (or developmental equivalent) Chronological Age: 4 years (or developmental equivalent) Behavior is not due exclusively to the direct physiological effect of the following: Behavior is not due exclusively to the direct physiological effect of the following: Substance (e.g., laxatives) Substance (e.g., laxatives) General Medical Condition except constipation General Medical Condition except constipation

23. Encopresis: Diagnostic Criteria Encopresis Encopresis Code as follows: Code as follows: 797.6 With Constipation and Overflow Incontinence 797.6 With Constipation and Overflow Incontinence 307.7 Without Constipation and Overflow Incontinence 307.7 Without Constipation and Overflow Incontinence

24. Encopresis: Prevalence 1-2% of the child population 1-2% of the child population Boys are 3-6 times more likely to have it than girls Boys are 3-6 times more likely to have it than girls Mean onset is 7 years old Mean onset is 7 years old 95% of children referred for treatment of encopresis have constipation 95% of children referred for treatment of encopresis have constipation

25. Encopresis: Etiology Little support for genetic basis for the disorder Little support for genetic basis for the disorder Little support for emotional and behavioral problems associated with encopresis Little support for emotional and behavioral problems associated with encopresis More a problem of dysfunction of the bowel More a problem of dysfunction of the bowel

26. Encopresis: Etiology Rule Out Hirschsprung Disease Rule Out Hirschsprung Disease Absence of ganglion cells and normal peristaltic waves in one segment of the bowel Absence of ganglion cells and normal peristaltic waves in one segment of the bowel Develop a megacolon Develop a megacolon Risk for impaction Risk for impaction Seepage of liquid stool Seepage of liquid stool

27. Encopresis: Assessment Medical Assessment Medical Assessment Rule out Hirschprung’s Rule out Hirschprung’s Any constipating medications Any constipating medications Diet (i.e., fiber intake, water) Diet (i.e., fiber intake, water)

28. Encopresis: Assessment Behavioral Assessment: Interview Behavioral Assessment: Interview Toilet training history Toilet training history Any behavioral or emotional problems Any behavioral or emotional problems Recent stressful precipitating events Recent stressful precipitating events Current status of toileting habits and bowel movements Current status of toileting habits and bowel movements

29. Encopresis: Assessment Behavioral Assessment: Interview Behavioral Assessment: Interview Environmental contributors (e.g., routine, diet and exercise) Environmental contributors (e.g., routine, diet and exercise) Consequences (e.g., parental reactions, child reactions) Consequences (e.g., parental reactions, child reactions) Child motivation for treatment Child motivation for treatment

30. Encopresis: Assessment Behavioral Assessment: Recording Data Behavioral Assessment: Recording Data Provide Chart for recording bowel movements Provide Chart for recording bowel movements Assess place, number of voids, size and consistency of void, reaction Assess place, number of voids, size and consistency of void, reaction Record fiber intake and exercise Record fiber intake and exercise

31. Encopresis: Treatment Combination of medical and behavioral treatment the most effective approach Combination of medical and behavioral treatment the most effective approach Medical Treatment Medical Treatment Clean out the bowel Clean out the bowel Enemas Enemas Laxatives Laxatives Increase fiber and exercise Increase fiber and exercise Ensure regular bowel movements Ensure regular bowel movements

32. Encopresis: Treatment Behavioral Treatment Behavioral Treatment Scheduled toilet sits Scheduled toilet sits After meals or suppositories/laxatives After meals or suppositories/laxatives Make relaxing Make relaxing Keep brief (e.g., 5-10 minutes) Keep brief (e.g., 5-10 minutes) Reinforcers for sits and then poops in the toilet Reinforcers for sits and then poops in the toilet Minimize reaction to accidents Minimize reaction to accidents