Potty Problems

1. Potty Problems Wetting and Soiling (Enuresis and Encopresis) Presented by: Amanda Wagley

2. Formal Definitions DSM IV Enuresis, 307.6 A.     Repeated voiding of urine into bed or clothes (whether involuntary or intentional). B.   The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupa­tional), or other important areas of functioning. C.   Chronological age is at least 5 years (or equivalent developmental level). D.  The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition ( e.g., diabetes, spina bifida, a seizure disorder)

3. Formal Definitions Cont. DSMIV Encopresis 787.6, 307.7 (w/or w/o constipation and overflow inconsistence) A.      Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional. B.       At least one such event a month for at least 3 months. C.       Chronological age is at least 4 years (or equivalent developmental level). D.      The behavior is not due exclusively to the direct physiological effects of a substance     (e.g., laxatives) or a general medical condition except through a mechanism involving constipation.

4. Who Has it? • Mostly 5-7 year olds • More common in boys (2:1) • Can affect girls and older children too • Genetics • Encopresis is not as common as enuresis • Encopresis without constipation is more rare • Can be a sign of abuse (sexual or physical) (Shapira & Dahlen, 2010) & (Coehlo, 2011)

5. Types of Enuresis • Primary • Occurs 2-3 times per week • Secondary • Occurs when a child starts wetting after several months or years without an “episode” • Usually brought on by additional stressors • Divorce • New Home • New Baby • Nocturnal • Occurs only at night • Most common form of Enuresis is primary nocturnal (aacap.org, 2004)

6. Could it be something else? • Urinary tract infection • Diabetes (Enuresis) • Sickle Cell (Enuresis) • Seizures • Spina bifida • Constipation • Pain passing stool (Encopresis) (Geroski & Rogers, 1998)

7. Causes/Characteristics Enuresis Encopresis • Sleep arousal difficulties • Production of large amounts of urine • Bladder dysfunction (overactive or small bladder) • Developmental delays • Low level of ADH hormone • Learning difficulties • Behavioral problems • Family problems (specifically parental separation) (Norfolk & Wootton, 2011) • Painful or unpleasant bowel movement • Chronic constipation • Low muscle tone • Slow intestinal motility • Atypical attention span • Fear from flushing toilet • Sexual abuse • Lack of exercise and/or water • Diets high in fats and sugar • OCD (Coehlo, 2011)

8. Common Comorbidities • ADHD • Depression • Anxiety Disorders • ODD (Akça, Aysev, & Aycan, 2011) • Select Mutism (Wong, 2010) • Sleep Disorder (aacap.org)

9. What Can We Do? Enuresis • DO NOT PUNISH! • Bladder Stretching • Pharmacology • Desmopressin • Synthetic analog of ADH • Anti-depressants (Tofranil) • Reduce irritability of the bladder muscles • Both have about 50%-80% success rate with about 60% -90% relapse. • Behavior Modification • Cleanliness Exercises • Reward Interventions • Limit Fluid intake • Enuresis Alarm • Urine sensitive pad connected to an alarm (Shapira & Dahlen, 2010)

10. Enuresis Alarm

11. What Can We Do? Encopresis • DO NOT PUNISH! • Pharmacology • Stool Softeners • Laxatives • Suppositories • Bowel Training • Teaches the child how to know when they need to use the restroom • Behavior Management • Punishment does not work • Maintain regular bathroom routines • Cleanliness exercises • Positive reinforcement • Nutritional Changes • Add fiber and bran • Decrease foods high in fat and sugar • Family Support • Self esteem • Depression (Coehlo, 2011)

12. If Left Untreated • Most will grow out if it on their own • Can lead to: • Depression • Low self-esteem • Negative Self-image • Negative affects on Peer relationships • Can lead to behavioral and emotional problems • The psychological and emotional effects can cause more damage than the disorder itself. (Shapira & Dahlen, 2010), (Norfolk & Wootton, 2011)

13. Steps for School Counselors • Normalize the situation for the child • Let them know they are not alone. • Educate parents • Help the parents and the child cope • Provide suggestions for further reading • Suggest a medical evaluation by a pediatrician • Refer to a pediatric counselor (Erford, 2011)

14. Helping Professionals • Counselors • Focus on “normalizing” • Overcome embarrassment • School Nurses • Pediatricians & Pediatric Nurses • Rule out underlying medical causes • Possibility of an immature bladder or bladder dysfunction • Write prescriptions in needed • Specialist Enuresis Nurses

15. Further Reading • Childhood Encopresis and Enuresis: Causes and Therapy • Overcoming Bladder & Bowel Problems in Children • Seven Steps to Nighttime Dryness: A Practical Guide for Parents of Children with Bedwetting

16. Reading for Kids • Everyone Poops • Clouds and Clocks: A Story for Children Who Soil • Sammy the Elephant & Mr. Camel: A Story to Help Children Overcome Bedwetting • Zumar the Alien: An Interplanetary Tale of Bedwetting

17. Resources • US Department of Health and Human Services • National Kidney & Urologic Diseaseshttp://kidney.niddk.nih.gov/KUDiseases/pubs/bedwetting_EZ/index.aspx • CHKD Treatment Center • http://www.chkd.org/HealthLibrary/Content.aspx?pageid=P01992 • http://www.chkd.org/HealthLibrary/content.aspx?pageid=P02206 • Education and Resources for Improving Childhood Continence (ERIC) http://www.eric.org.uk/ • www.ucanpooptoo.com • Counselors/Therapists in Hampton Roads • http://therapists.psychologytoday.com/rms/name/Pat_Davis_LPC,LMFT,NBCC_Virginia+Beach_Virginia_85097

18. Resources Cont. • The Bedwetting Store • http://bedwettingstore.com/?gclid=CMjr5uvlj64CFSU0QgodUmztBg • Enuresis Treatment Center • www.drybed.com • American Academy of Pediatrics • www.aap.org • American Urological Association Foundation • www.auafoundation.org • National Association for Continence • www.nafc.org

19. References • American Academy of Child and Adolescent Psychiatry. (December 2011). Facts for families: bedwetting. Retrieved from www.aacap.org. • American Academy of Child and Adolescent Psychiatry. (November 2004). Facts for families: problems with soiling and bowel control. Retrieved from www.aacap.org. • Akça, Ö., Aysev, A., & Aycan, İ. (2011). Familial features and comorbid psychiatric disorders in children with encopresis. Bulletin of Clinical Psychopharmacology, 21(4), 345- 352. • American Psychiatric Association. (2004). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, D.C.: Author. • Coehlo, D. (2011). Encopresis: a medical and family approach. Pediatric Nursing, 7(3),107- 112. Erford, B. (2011). Transforming the school counseling profession. Upper Saddle River, New Jersey: Pearson Education, Inc. • Geroski, A. & Rodgers, K. (1998). Collaborative assessment and treatment of children with enuresis and encopresis. Professional School Counseling, 2(2). 128. • Norfolk, S. & Wootton, J. (2011). Supporting children with nocturnal enuresis. British Journal of School Nursing, 6(5), 225-228. • Shapira, B. & Dahlen, P. (2010). Therapeutic treatment protocol for enuresis using an enuresis alarm. Journal of Counseling &Development, 88, 246-252. • Wong, P. (2010). Selective mutism: a review of etiology, comorbidities, and treatment. Psychiatry (1550-5952), 7(3), 23-31.