Elimination disorders
Elimination disorders, which include encopresis (fecal incontinence) and enuresis (urinary incontinence), are conditions characterized by inappropriate urination or defecation in individuals who are typically beyond the age of toilet training. These disorders primarily affect children, with encopresis impacting approximately 1.6 to 4 percent of those under ten years old, more frequently in boys, while enuresis is notably common, especially in the form of nocturnal bed-wetting. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) outlines specific criteria for diagnosing these conditions, emphasizing the need for social and emotional considerations as children with these disorders can face embarrassment, ridicule, and potential long-term psychological effects.
While elimination disorders often relate to physical conditions like constipation, they can also signal underlying psychological issues, particularly when a child has control over their bowel or bladder but still engages in inappropriate elimination. Factors such as stress, behavioral problems, or a history of trauma, including abuse, may be linked to these disorders. Treatment approaches vary, focusing on both medical and psychological interventions, and emphasize understanding, patience, and emotional support to foster the child's overall psychological well-being. Awareness of these disorders and their implications can promote a supportive environment for affected children and their families.
Elimination disorders
- TYPE OF PSYCHOLOGY: Psychopathology; social psychology; stress
Elimination disorders, in which a person urinates or defecates in inappropriate places after the age that toilet training should have occurred, affect a significant number of children. These embarrassing events can separate a child from their peer group and stunt proper psychological growth.
Introduction
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), published in 2022, defines elimination disorders—encopresis and enuresis—as the excretion of feces or urine, respectively, in areas other than those deemed socially acceptable, such as the toilet. For a psychiatrist to give this diagnosis, a child must experience at least one such elimination per month (encopresis) or two per week (enuresis) for a minimum of three consecutive months—or, in the case of enuresis, "clinically significant distress or impairment in social, academic (occupational) or other important areas of functioning"—once the child has reached the age at which proper waste disposal is considered a normal developmental skill. In general, children with elimination disorders do not have control of their bodily functions; therefore, the disorders are often considered the result of a physical condition or abnormality. However, children who do have rectal and bladder control will occasionally discharge urine or fecal matter voluntarily. This is usually an indication of an underlying psychological problem that requires thorough psychiatric evaluation.
The Society of Pediatric Psychology (SPP) has reported that an estimated 1.6 to 4 percent of children under ten experience encopresis, also known as fecal incontinence, with a higher prevalence among boys than girls. While the condition affects a significant number of children aged three and under, by fewer than 1 percent of the age group has this condition. Encopresis is often caused by constipation. In this case, a parent or caregiver will notice fecal leakage in a child’s diaper or underwear. Constipation occurs because of a blockage in the rectum. Over time, the impacted fecal matter may dull the nerve endings in the rectum, further hindering a child from recognizing when a bowel movement is imminent. Almost all children in Western, industrialized countries are able to control their bowels by age five. Therefore, a child with encopresis after their fifth birthday may be subject to embarrassment, ridicule, or punishment within the context of a school environment. This situation can adversely affect the child’s psyche, causing residual damage and potential future psychiatric disorders.
During a child’s toddler years, enuresis, the inappropriate discharge of urine, is considered a normal aspect of development. In fact, enuresis is not considered a valid diagnosis for any child under five years old. If the activity persists into school-age years, it is considered a disorder; by age six, according to the SPP, approximately 25 percent of boys and 15 percent of girls still experience enuresis, usually in the form of bed-wetting. Nocturnal enuresis is the most common form of the disorder, approximately three times more prevalent than diurnal, or daytime, enuresis, and is the least embarrassing because it usually occurs separately from the scrutiny of the peer group. Diurnal enuresis is more common among girls than boys and may result from a physiological condition, physical stress such as laughter or athletic activity, or simply the child being preoccupied with other matters or reluctant to use available restrooms. As with encopresis, enuresis during daytime hours can cause embarrassment, which, in turn, can be damaging psychologically.
Psychological Issues Related to Elimination Disorders
Evidence suggests that certain psychological issues, while not the primary causes of the problem, may predispose a child to either encopresis or enuresis. Conversely, psychological issues often arise in children with elimination disorders. If a child is intentionally engaging in inappropriate defecation or urination, they may have additional behavioral problems or may be reacting to some new stress in their life. Also, a child may use voluntary elimination as a symbolic gesture of anger toward a parent or guardian. Evidence also indicates that children who have been sexually abused experience elimination disorders at higher rates than children who have not been abused, though an elimination disorder is not by itself a sufficient indication of abuse. In such a case, the child’s defecation or urination may be intentional but is most likely a subconscious reaction to the abuse.
Aftereffects of elimination disorders suggest a link between the problem and lingering psychological and psychiatric issues. Apart from the initial embarrassment and shame, individuals with elimination disorders may experience longer-term and more serious problems. A 2009 study by Shreeram et al. found that children with attention-deficit hyperactivity disorder (ADHD) were more likely to experience enuresis than their peers. Low self-concept, aggressive behaviors, social problems, and poor emotional regulation have been shown to occur more often in these individuals. In general, mental health conditions have a greater likelihood of surfacing in people who had enuresis as children, though whether enuresis is more likely to be an early indication or a precipitating factor is unknown.
Medical and Psychological Treatment
Before undertaking medical or psychological treatment, a professional must determine whether the condition in question is primary, occurring in a child who has yet to be properly toilet trained, or secondary, occurring after a significant period in which the child displayed proper toilet training. A child with a secondary disorder might have emotional issues requiring further diagnostic psychiatric evaluation. On the other hand, a child with encopresis might only need to be taught proper etiquette, undergo a change in food consumption, or start a regimen of scheduled bathroom breaks. A child who experiences nocturnal enuresis might be assigned “bell and pad” therapy, which involves sleeping on a pad that provides electronic notification when elimination has occurred; using this method, the child will eventually wake before urinating in bed. Drugs such as imipramine are available for enuresis, but relapse often occurs once the child has been weaned off the medication. Regardless of the degree to which a child experiences elimination disorders, all treatment should be administered with understanding, patience, and emotional sympathy while considering the long-term psychological well-being of the individual. Adults with elimination disorders often experience barriers to care due to a lack of treatment guidelines and evidence-based treatment methods. Because the condition is rare in children and even rarer in adults, many practitioners struggle to properly address the cause of the problem.
Bibliography
Bhandari, Smitha. "Elimination Disorders and Encopresis in Children." WebMD, 26 Feb. 2024, www.webmd.com/mental-health/elimination-disorders-encopresis. Accessed 1 Oct. 2024.
Boland, Robert Joseph, and Marcia L. Verduin. Kaplan and Sadock’s Concise Textbook of Clinical Psychiatry. 5th ed., Lippincott Williams & Wilkins Wolters Kluwer, 2023.
Berhanu, Tamene, et al. “Elimination Disorders and Associated Factors among Children and Adolescents Age 5–14 Year-Old Attending Paediatric Outpatient Clinic at Wolaita Sodo University Comprehensive Specialized Hospital, South Ethiopia.” Child and Adolescent Psychiatry and Mental Health, vol. 18, no. 1, 2024. doi.org/10.1186/s13034-024-00739-7. Accessed 14 Nov. 2024.
Christophersen, Edward R., and Patrick C. Friman. Elimination Disorders in Children and Adolescents. Hogrefe, 2010.
Frances, Allen. Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5. Guilford, 2013.
Gontard, Alexander von. “The Impact of DSM-5 and Guidelines for Assessment and Treatment of Elimination Disorders.” European Child & Adolescent Psychiatry, vol. 22, 2013, pp. S61–7. doi.org/10.1007/s00787-012-0363-9. Accessed 14 Nov. 2024.
Marsh, Eric J., et al. Child Psychopathology. 8th ed., Guilford, 2024.
Martin, Garry, and Joseph Pear. Behavior Modification: What It Is and How to Do It. 12th ed., Pearson, 2024.
Reichenberg, Lourie W. DSM-5 Essentials: The Savvy Clinician's Guide to the Changes in Criteria. Wiley, 2014.
Seligman, Linda, and Lourie W. Reichenberg. Selecting Effective Treatments: A Comprehensive, Systematic Guide to Treating Mental Disorders. 5th ed., Wiley, 2016.
Shreeram, Srirangam, et al. “Prevalence of Enuresis and Its Association with Attention-Deficit/Hyperactivity Disorder among U.S. Children: Results from a Nationally Representative Study.” Journal of the American Academy of Child and Adolescent Psychiatry, vol. 48, no. 1, 2009, pp. 35–41. doi.org/10.1097/CHI.0b013e318190045c. Accessed 14 Nov. 2024.