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Vol. 20 no. 2
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theories tended to characterize enuresis with psychopathology
(Christophersen & Friman, 2010). A current literature review,
however, shows more research support for biobehavioral
models. These models list etiological factors from a variety
of possibilities including maturational delay, stressful and/
or traumatic life events, psychosocial concerns, learning and
modeling, genetics, sleep dynamics, or a combination of these
factors.
There are several options for treatment of nocturnal
enuresis. A well-known behavioral treatment is referred to as
the “bell-and-pad” procedure. This protocol was first devel-
oped in the 1930s and consists of a urine-sensitive pad that is
connected to a buzzer alarm or bell. The pad is placed under
the child at bedtime and the alarm sounds to wake the child
when he or she begins to urinate. Over time, the child is sensi-
tized to the sensation of having a full bladder. This method
boasts a success rate of approximately 75% (Barkoukis, et al.,
2008; Christophersen & Friman, 2010). Variations of this
method are now available including pajama devices, vibrating
alarms for the child, and pagers for parents.
Other behavioral treatments include a combination of
psychoeducation, positive reinforcement, arousal training
utilizing an alarm, psychotherapy, biofeedback, positive prac-
tice, and family encouragement. Some physicians also use drug
treatments, but behavioral treatments for enuresis are typically
preferred due to fewer side effects and longer lasting impact.
Furthermore, controlled trials show better support for alarm-
based treatment compared to pharmacological approaches
(Christophersen & Friman, 2010; Yarhouse, et al., 2005).
Treatments for diurnal enuresis include psychoeducational
methods (e.g., cueing and motivating, teaching Kegel exercises
to improve muscle tone, urine alarms/vibrators, and psycho-
therapy). There is less research on diurnal versus nocturnal
enuresis.
Encopresis
Encopresis is diagnosed when a child of at least four years of
age exhibits loss of a stool in inappropriate places at least once
per month for three consecutive months. The episodes may
be involuntary or intentional. Primary encopresis refers to
children who have never responded to potty-training, while
secondary encopresis applies to children who were toilet-
trained at one time, but then resumed soiling. Physiological
causes, other than constipation, need to be ruled out before
diagnosing encopresis. Prevalence estimates for encopresis
range from 1–3%, and the disorder is more common in boys
than girls.
There are many theories regarding the causes of encop-
resis, including coercive potty-training, sexual abuse, trauma,
or psychosocial stressors. The comorbid condition most clearly
supported in literature is constipation (Christophersen &
Friman, 2010). Over 90% of children referred for treatment
report constipation. Constipation may be caused from a
variety of factors, including diet, medication side effects,
emotional stress, or frequent changes in daily routines.
Treatment typically starts with a physician, since the first
step is assessment for physical causes. Laxative treatment,
suppositories and/or dietary measures may be prescribed
to address the constipation. This may take place whether
or not organic pathology is found to explain the soiling. If
there are no physical explanations for the chronic constipa-
tion or soiling, then a psychological assessment is in order.
Assessment should include questions regarding the medical
history of the child and family, the child’s diet, potty-training
history, current stressors, the psychosocial environment, and
information about the course of the encopresis along with any
previous attempts to address the issue.
A recommended first step of therapeutic treatment is
parent education to ensure them that their child is most
likely not soiling on purpose. Psychotherapy may help
address any emotional distress, family pressures, or behav-
ioral issues. If there are other common comorbid conditions
(e.g., Oppositional Defiant Disorder, ADHD, anxiety, or
Adjustment Disorder), then they should also be included in a
treatment plan.
In conclusion, enuresis and encopresis are most often
accompanied by shame and embarrassment for children, as
well as their parents. Christian counselors can play an impor-
tant role in educating parents and helping identify and address
the root causes. As children overcome these conditions and
the associated shame, they are better able to embrace and grow
in their God-given nature.
✠
Trina Young Greer. Psy.D.,
is a Licensed
Clinical Psychologist and the Executive Director of
Genesis Counseling Center, an outpatient counseling
group with multiple offices located in Hampton Roads,
Virginia, providing comprehensive Christian counseling
and psychological and psychiatric services. Dr. Greer
obtained her Doctorate of Psychology degree from Regent University. Her
specializations include working with children, trauma recovery, and
leadership.
References
American Psychiatric Association (2013).
Diagnostic and Statistical Manual
of Mental Disorders
(5th ed.). Washington DC: American Psychiatric
Association.
Barkoukis, A., Reiss, N. & Dombeck, M. (2013, May 20).
Elimination
Disorders
. Retrieved from minddisorders.com/Del-Fi/Elimination-
disorders.
Christophersen, E.R. &Friman, P.C. (2010).
Elimination Disorders in
Children and Adolescents
. Cambridge, MA: Hogrefe Publishing.
Yarhouse, M.A., Butman, R.E. & McRay, B.W. (2005).
Modern
Psychopathologies: A Comprehensive Christian Appraisal
. Downers
Grove, IL: InterVarsity Press.
