Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders

Abstract

Pediatric elimination disorders are common in childhood, yet psychosocial correlates are generally unclear. Given the physiological concomitants of both enuresis and encopresis, and the fact that many children with elimination disorders are initially brought to their primary care physician for treatment, medical evaluation and management are crucial and may serve as the first-line treatment approach. Scientific investigation on psychological and behavioral interventions has progressed over the past couple of decades, resulting in the identification of effective treatments for enuresis and encopresis. However, the body of literature has inherent challenges, particularly given the multicomponent nature of many of the treatment packages. This review identified 25 intervention studies-18 for nocturnal enuresis and 7 for encopresis-over the past 15 years and classified them according to the guidelines set forth by the Task Force on the Promotion and Dissemination of Psychological Procedures. For nocturnal enuresis, the urine alarm and dry-bed training were identified as well-established treatments, Full Spectrum Home Therapy was probably efficacious, lifting was possibly efficacious, and hypnotherapy and retention control training were classified as treatments of questionable efficacy. For encopresis, only two probably efficacious treatments were identified: biofeedback and enhanced toilet training (ETT). Best practice recommendations and suggestions for future research are provided to address existing limitations, including heterogeneity and the multicomponent nature of many of the interventions for pediatric elimination disorders.

Complementary and Integrative Management of Pediatric Lower Urinary Tract Dysfunction Implemented within an Interprofessional Clinic

“…For bowel dysfunction, enhanced toilet training (ETT) is an evidence-based, combined medical-behavioral intervention for constipation and encopresis that pairs laxative therapy with behavioral modification techniques, education, and training about appropriate defecation dynamics, including modeling of breathing techniques, abdominal muscle straining, and relaxation of the pelvic floor muscles [33]. As with behavioral interventions for LUTD, ETT incorporates daily diaries to monitor toileting patterns and contingency-based rewards to reinforce adaptive defecation dynamics, motivation, and adherence [16].…”

“…Although subclinical psychosocial symptoms tend to remit with improvements in bladder and bowel functioning, clinically significant behavioral and emotional disorders are more pervasive and are more likely to impact treatment adherence and overall outcomes [15]. Therefore, integrating early screening, education, and treatment of underlying psychological conditions into medical treatment protocols is recommended, particularly in consideration of the biobehavioral framework of LUTD [16].…”

Doctor, Snitch, and Weasel: Narrative Family Therapy With a Child Suffering From Encopresis and Enuresis

“…Parents may experience psychological and social stress as they struggle to identify ways to positively manage their child’s toileting behaviors (Ritterband et al, 2003). There is some evidence that a child’s self-esteem improves with incorporating caregivers in enuresis treatment, but effective treatment for encopresis remains elusive (Shepard, Poler, & Grabman, 2017).…”

“…Although enuresis and encopresis may affect both the diagnosed child as well as family members (Olaru et al, 2016), the majority of established treatments focus individually on the child. When a child presents to their primary care physician with enuresis, treatment approaches typically begin with behavioral interventions such as urine alarm therapy and dry-bed training and may progress to include medication (e.g., desmopressin; Shepard et al, 2017). Urine alarm therapy is an intervention where a moisture sensor is placed in the child’s pajamas or the child sleeps on a pad with a moisture sensor to trigger an alarm when urination begins, so the child can get to the toilet to finish urinating (Shepard et al, 2017).…”

“…When a child presents to their primary care physician with enuresis, treatment approaches typically begin with behavioral interventions such as urine alarm therapy and dry-bed training and may progress to include medication (e.g., desmopressin; Shepard et al, 2017). Urine alarm therapy is an intervention where a moisture sensor is placed in the child’s pajamas or the child sleeps on a pad with a moisture sensor to trigger an alarm when urination begins, so the child can get to the toilet to finish urinating (Shepard et al, 2017). Similarly, dry-bed training is an intensive procedure that involves giving a child fluid before bedtime and then being woken up hourly by an alarm to go to the bathroom (Azrin, Sneed, & Foxx, 1974).…”