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

Encopresis

Definition
Prevalence
Etiology and Consequences
Assessment/Treatment
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 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

Brazeltons 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 childs 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 Foxxs 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
diapercomfort, 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: Whats 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 (Contd)

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 UrineAlarm 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 (Contd)

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?
Hirschsprungs disease

Etiology (Contd)

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
childs 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 parents
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 (Contd)

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 MedicalBehavioral
For Manipulative
Soiling

Behavioral and family

therapy
Coping and communication
skills emphasized
Reward appropriate
behaviors and do not
reinforce soiling behavior

Other Treatment
Approaches (Contd)

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

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/division-54/evidence-based/factsheets.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.