Abstract
Elimination disorders are two very common disturbances affecting children. This paper discusses enuresis and encopresis, which are the two major categories of elimination disorders. Enuresis is defined as the inappropriate deposit of urine while encopresis is the inappropriate passing of stool. The paper notes that disorders are often functional, which means that they are not caused by medical conditions. The causes of the disorders, which include slow maturation of the child’s elimination system and emotional disorders are highlighted. The role that parents and guardians play in exacerbating the condition is noted. The paper then reviews the various negative consequences of elimination disorders and proceeds to discuss the treatment options that can help cure enuresis and encopresis. It is recommended that behavioral and medical interventions should be used together to achieve the best results.
Introduction
Children are likely to face several health disturbances when growing up. A very common group of disturbances experienced during childhood is elimination disorders. Elimination disorders are childhood disturbances characterized by urinary incontinence or soiling by children beyond a certain age. While these problems are common, they are often overlooked since they are assumed to be within the area of normal child behavioral problems that disappear naturally after some time. Klykylo and Jerald (2012) observe that some parents do not bring up the issue of elimination disorders with primary care clinics professionals. However, it has been recognized that elimination disorders are of significant concern and they should not be overlooked as typical conditions in childhood development. Normally developing children are expected to have achieved bowel and bladder continence by a certain age. If mastery of elimination is not achieved by a certain age, then the child might be suffering from elimination disorders. Elimination disorders can have some negative implications on the long-term mental health of the child. It is therefore advisable to identify them and provide treatment to the afflicted child.
Definition
Elimination disorders refer to a heterogeneous group of disturbances involving the elimination of urine or feces. Gontard (2011) notes that these disturbances can be divided into two distinct subtypes; enuresis and encopresis.
Enuresis
Enuresis is defined as the voluntary or involuntary releasing of urine, either on clothes or in bed, by children above 5 years of age. The child’s age is critical in defining enuresis since before the period specified, the prevalence of urinary incontinence in children is high. Gontard (2011) documents that 20-25% of 4-year-old children still wet themselves or their beds. This high prevalence suggests a normal developmental phenomenon and diagnosing a disorder at this age would be misleading. Enuresis can further be subdivided into two depending on whether it occurs during the day or at night. If the voiding of urine takes place while the child is asleep, it falls under nocturnal enuresis while if it occurs during daytime it falls under the diurnal enuresis category. Research indicates that enuresis is common with nocturnal enuresis affecting 10% of 7-year-olds while diurnal urinary incontinence affects 2-3% of children between 5 and 7 years (Gontard, 2011). Enuresis is further classified as primary or secondary. Primary enuresis describes when urinary continence is never accomplished through the night while secondary enuresis describes when the child achieves continence for 6 months or more but then starts wetting again. Primary enuresis is attributed to maturational delays while secondary enuresis is caused by psychological or underlying medical conditions.
Encopresis
This disorder is characterized by the excreting of feces in inappropriate places other than toilets such as in clothes or on the floor by children above 4 years of age. As with enuresis, age is critical in the definition of encopresis since excreting feces in inappropriate places is expected of children before they reach a certain age. This passage of feces can be voluntary or involuntary and it has to take place over 3 months or more. Functional constipation is a disorder that often appears together with fecal incontinence. It is important to differentiate encopresis from soiling. Shona and Carney (2004) assert, “While soiling is the involuntary passage of fluid or semi-solid stool into the clothing, encopresis is the passage of normal stool into an inappropriate place” (p.126).
Causes of Elimination disorders
The primary cause of involuntary enuresis is when the child fails to gain control of the urinary mechanism. This is caused by the slow maturation of the child’s elimination system. The child will therefore be unable to retain feces at an age when most of his/her peers have attained bowel control mastery. Cheng and Myers (2010) observe that this slow maturity might be the result of problematic and overly harsh toilet training. Harsh training often involves toilet training by the parent at an inappropriate age and it can result in elimination disorders. Some parents begin toilet training their children when the child is not yet ready for this task. Problematic toilet training experiences make the child develop significant anxieties about passing stool or urine. This can lead to toilet phobia, which will cause elimination disorders.
Emotional trauma has been recognized as a possible cause of elimination disorders. Children who have been abused may at times of stress become disorganized and overwhelmed. This state of being overwhelmed is manifested as urine or stool accidents. In addition to this, elimination disorders can be caused by psychological problems experienced by the child. Klykylo, W., & Jerald, K. (2012) observes that children with defiant issues can use inappropriate feces depositing as a form of retaliation or to express anger against their parents or guardians. In these cases, the inappropriate discharge of stool or urine is done with the sole intention of aggravating the adult.
Consequences of Elimination Disorders
Equit and Braun-Bither (2014) state that elimination disorders result in some negative psychological effects on the individual. Their study reveals that children with elimination disorders showed anxiety and depression levels that were significantly higher than those of children without these disorders were. Symptoms such as sadness, depression, withdrawal, and anxiety are often observed in children with elimination disorders. Emotional problems may develop in children with encopresis and enuresis because of being teased or embarrassed about their condition. The psychological problems can include poor self-esteem, anxiety, reduced school performance, and impaired social success.
Elimination disorders have been associated with problematic behavior throughout the lives of the affected children. Cheng and Myers (2010) document that elimination disorders have been associated with tantrums and school refusal. In addition to this, children develop deviant behavior and may engage in crimes such as fire settings.
Diagnosis
Early identification and treatment of elimination disorders may help prevent some of the devastating emotional problems associated with the disorder. Gumaer (2010) asserts that the longer the problems exist, the more chronic they become. For a diagnosis of Enuresis to be made, the child has to be above 5 years old and he/she must repeat this behavior at least twice a week. The behavior is only regarded as clinically significant if the voiding of urine takes place over 3 months or more. For encopresis to be diagnosed, the child should be 4 years or above and he must demonstrate inconsistency for over 3 months. Children with encopresis may have long intervals between bowel movements and they often experience abdominal discomfort and appetite changes. The American Psychiatric Association (2013) documents that over 50% of the children with encopresis report experiencing abdominal pain during the day or before the evacuation of stool.
Treatment
For both enuresis and encopresis, the treatment efforts start with educating the child’s parents or guardians on the issue. Gumaer (2010) asserts that demystification of the problem is the most important step in treating elimination disorders. Most children and their families are unaware that elimination disorders are a real problem that affects a segment of the population. Due to ignorance, children are punished, blamed, or shamed for their condition. Parental education emphasizes the fact that it is not the child’s fault that he/she is suffering from elimination disorders. By explaining the underlying causes of the disorders, the parents can take positive steps to help the child overcome the disturbances.
Medical and behavioral interventions are used to treat elimination disorders. In dealing with clinical enuresis, the behavioral intervention involves the bell and pad. This behavioral modification technique makes use of classical and operant conditioning to train the child to overcome the voiding of urine while asleep. This method works by ringing a bell whenever the child begins to urinate while asleep. The child seeks to avoid triggering the alarm and this leads to bladder control. Studies indicate that there is an 80-90% success rate of the bell and pad technique (Klykylo & Jerald, 2012). To deal with diurnal enuresis, timed trips to the restroom can be used. This behavioral intervention method only requires the investment of a watch that has a countdown timer. The behavioral strategies used to treat encopresis include creating a schedule for evacuation. The rationale for a schedule for evacuation is that the bowel wall is stretched making it impossible to send the brain signals for defecation. The child is therefore unaware of his/her need to pass stool. The intervention will therefore require the child to be made to defecate even if he/she does not feel the need to.
Pharmacological interventions are effective in dealing with elimination disorders. In the United States, desmopressin and imipramine are often used to treat enuresis. These drugs act by releasing chemicals into the bloodstream, from where active elements travel to the kidney. Here they act as V2 receptors in the collecting ducts and distal tubules reducing urine output. It is recommended that the drugs be administered for 6 months and then stopped for 2 months to see if a cure has been effected. Laxative therapy can be applied for the management of constipation, which accounts for 90% of the encopresis cases. Studies indicate that the best results are achieved when behavioral interventions are augmented with medication.
Conclusion
The paper has observed that children first obtain bowel control followed by bladder control during sleep and wakefulness. It defined elimination disorders are the difficulties experienced by children in controlling their bowels and bladders. The paper has noted that diagnosis of enuresis and encopresis should only be diagnosed when the child is at a developmental point where he/she should be able to demonstrate elimination mastery. The paper has identified the causes of these disorders and the various impacts they might have on the lives of the child. Treatment options that include supportive approaches, behavioral programs, and medication have been discussed. By understanding and dealing with elimination disorders, the issue can be dealt with and the psychosocial consequences associated with the problems avoided.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Boston: American Psychiatric Publishers.
Cheng, K., & Myers, K. (2010). Child and Adolescent Psychiatry: The Essentials. NY: Lippincott Williams & Wilkins, 2010.
Equit, M., & Braun-Bither, K. (2014). Elimination disorders and anxious-depressed symptoms in preschool children: a population-based study. European Child & Adolescent Psychiatry, 23(6), 417-423.
Gontard, A. (2011). Elimination disorders: a critical comment on DSM-5 proposals. European Child & Adolescent Psychiatry, 20(2), 83-88.
Gumaer, J. (2010). Multimodal counseling of childhood encopresis: A case example. School Counselor, 38(1), 58-65.
Klykylo, W., & Jerald, K. (2012). Clinical Child Psychiatry. NY: John Wiley & Sons.
Shona, M., & Carney, T. (2004). The Classification of Soiling and Encopresis and a Possible Treatment Protocol. Child & Adolescent Mental Health, 9(3), 125-129.