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| Scientific
Articles On Bedwetting and Soiling |
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This page features my own work and that of DJ Cox (the last article at the bottom of this page--which represents the latest systematic approach for the oral laxative approaches). You are invited to review the most recent abstracts from the extensive scientific literature at large using the hyperlink at the very bottom of this page. I believe any professionals out there will find my perusal of the literature to be very extensive. RWC | |
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| Enuresis
and encopresis are technical terms referring to functional difficulties
in bladder and bowel control, respectively. Eliminative control ordinarily
is accomplished in the sequence bowel-asleep, bowel-awake, bladder-awake,
bladder-asleep (Stein and Susser, 1967). Encopresis and diurnal (daytime)
enuresis can be recognized when a child is between 2 and 3 years of age.
The last stage of bladder control in sleep appears to be particularly difficult
to achieve for a significant minority of children from 4 to 5 years of age
and beyond. In fact, bedwetting (nocturnal enuresis) may be regarded as
the most chronic and prevalent of all childhood disorders. Organic causes and complications of bladder and bowel incontinence are almost always sought but rarely found. While maturational and hereditary mechanisms are undoubtedly implicated, they clearly interact with personal-societal concerns and toilet training procedures. The effectiveness of the various surgical, biochemical, and behavioral conditioning interventions attests to the highly interactive nature of enuresis or encopresis. The visibility of enuretic and encopretic symptoms lends an objectivity to clinical assessment procedures which is not generally found for other functional disorders. This realization, the robustness of modern medical and behavioral sciences, and the centuries old concerns surrounding soiling promise increased freedom from the problem of urinary and fecal incontinence. Background and Current Status Enuresis is a New Latin derivation from the Greek word enourein, meaning "to urinate in." Its incidence in children has been a cause of concern for centuries. Encopresis is a modern term, invented in the mid 1920s (Halpern, 1977). The general paucity of information on encopresis, until very recently, contrasts greatly with the much more copious information on enuresis. An almost phobic aversion to feces has apparently characterized most cultures to this time. For example, fecal incontinence is the primary reason for removing the elderly from home care and placing them in extended-care facilities (Atthowe, 1972). Nocturnal enuresis was recognized as worthy of attention as long ago as 1550 B.C., when it was described in the pediatric section of an ancient Greek volume (Glicklich, 1951). Thomas Phaer" the father of English pediatrics, headed a paragraph in his 1544 Boke of Children with the title "Of Pyssying in the Bedde" (Glicklich, 1951). Psychoanalytic speculation has suggested that enuresis is a form of aggression against the parents or a depression expressed in weeping through the bladder (Blackwell and Currah, 1973; Lovibond, 1964). In the modern era it rated an international conference in England (Kolvin, MacKeith, and Meadow, 1973). Encopresis should be viewed in the context of centuries-old concerns with promoting bowel movements, on the one hand, and inhibiting them to prevent soiling, on the other (Beekman, 1977). Both processes have been viewed as essential to good physical health. In Freud's view, even personality development is affected by the various outcomes or processes associated with achieving bowel control (Erikson, 1963; Fine, 1973, 1975); and psychoanalytic observers specifically attribute to the "anal stage" of personality development such traits as stubbornness, orderliness, pedantry, rebelliousness, a drive for autonomy, and a fondness for molding and manipulating. The worldwide incidence of nocturnal enuresis for children aged 4 years and older ranges from 10 to 33 percent (Cooper, 1973; deJonge, 1973; Kaffman and Elizur, 1977; Lovibond, 1964; Oppel, Harper, and Rider, 1968). The chronicity of bedwetting is reflected in the statistics from some twelve surveys, which indicate that the actual probability of a child's becoming dry in any twelve-month period for any age beyond 4 years is not more than 1 in 4 (Lovibond and Coote, 1970) and could be as low as one in seven (de Jonge, 1973). Even if the child does attain continence, the probability that he or she will relapse can be as high as I in 4 (Oppel, Harper, and Rider, 1968). Children who have relapsed are termed secondary or acquired enuretics. Functional urinary incontinence since birth is known as primary or persistent enuresis. The incidence of diurnal enuresis is much lower than that for nocturnal enuresis, from 2 to 5 percent (de Jonge, 1973). The presence of enuresis in the daytime is highly predictive of nocturnal enuresis. The reverse, diurnal enuresis given nocturnal enuresis, is somewhat less likely (de Jonge, 1973; Stein and Susser, 1967). However, some diurnal symptoms often remain for nocturnal enuretics in the form of frequency, urgency, and small bladder capacities (Lovibond and Coote, 1970; Zaleski, Gerrard, and Shokeir 1973). Parental and societal sensitivity to daytime urinary incontinence appears to be much greater than that to bedwetting, which can be somewhat more successfully hidden and tolerated. The incidence of encopresis in the Western world is about 1.5 percent, with boys manifesting the disorder much more often than girls (Bellman, 1966; Halpern, 1977). One should rule out the organic syndrome known as Hirschsprung's disease (involving an absence of nerve fibers in the rectum or large intestine) before diagnosing encopresis (Halpern, 1977; Wright, 1973); only about 5 percent of cases of fecal incontinence, however, are attributable to Hirschsprung's disease (Wright, 1973). There is little agreement on the nomenclature for the various forms of encopresis. Basically, there are the retentive and nonretentive forms. Retentive encopresis is most common (Bellman, 1966; Wright, 1975). It is characterized by frequent spotting throughout the day because of forced leakage around a large bolus or a fecallith. The nonretentive form is often associated with mental retardation or a lack of toilet training. As with enuresis, a further distinction can be made between primary and secondary encopresis, depending on whether or not the condition has been present from birth. CRITICAL DISCUSSION General Areas of Concern A lack of bladder and bowel control is a natural condition of infancy. The usual question, then, of why a given child is incontinent is not nearly so interesting as the question of why or how a child manages eventually to achieve bladder and bowel control. The recast question helps to avoid blaming maturation, heredity, stress, incompetent or malevolent parents, and/or a deeply disturbed child. Instead, these same factors can be viewed from the perspective of how they can be fostered, altered, or overcome to promote bladder and bowel continence. Both modern biomedical and behavioral scientific research give good cause to believe that progress is being made in dealing with this newer question. For example, the old question implied that incontinence must be explained in terms of some underlying emotional disorder. The evidence that has emerged from research on bedwetting strongly suggests that the opposite position is largely true. That is, the unfortunate persistence of incontinence in and of itself leads to personal and societal reactions, which are the bases for the accompanying emotional problems of a significant minority of enuretic and encopretic children (Lovibond, 1964; Shaffer, 1973; Yates, 1970). There are several ways in which physiological factors appear to be associated with incontinence. A contribution of heredity has often been suggested by the well-recognized familial incidence of enuresis. This observation has been strengthened by studies with identical twins (Bakwin, 1973). Maturational readiness for the development of bladder and bowel control is also important. The usual caution by child care experts, especially those of a psychoanalytic persuasion, is not to begin toilet training too early. However, toilet training after some given age may also be especially difficult to accomplish. One recent study, for example, supports the advantages of early toilet training initiated in the 16- to 19-month-old range (Kaffinan and Elizur, 1977). A higher rate of nocturnal enuresis was found for children over 4 years old when their toilet training had been delayed to after 20 months of age. Control of the retention or expulsion of waste products has to be tailored to complex societal demands about the appropriate time and place for elimination. This task, especially for a young child, is exceedingly complex. He or she must develop control over both the external and the internal milieu. Bedwetting is complicated even further because of its association with sleep, where the appropriate awareness and control is more difficult to accomplish. Here control may depend on awakening to toilet, accommodating more urine through the night, or even lessening the production of urine in sleep. One may well wonder how young children can possibly learn the complex toileting cues and skills required for continence. The development of potent behavior conditioning regimens for toilet training has answered some questions about what should be learned (Azrin and Foxx, 1974; Collins, 1973; Halpern, 1977; Mowrer and Mowrer, 1938; Wright, 1973, 1975); and the contention that these behavior therapy approaches may have undesirable psychological or physiological consequences has not been supported (Collins, 1973, 1976; Geppert, 1953; Yates, 1970). Comparative Philosophies and Theories The biomedical and behavioral perspectives have merged as the predominant means for dealing with enuresis and encopresis. With respect to enuresis, biomedical researchers stress such factors as an unstable bladder, a lack of coordination between the 3phincter and detrusor (bladder) muscle, and structural anomalies of the urinary tract. Their preferred modes of treatment are medication and surgery. Some degree of success has been achieved in treating enuresis with the tricyclic antidepressants (Blackwell and Currah, 1973), or by surgical transection of the bladder (Hindmarsh, Essenhigh, and Yeates, 1977), or by surgically invasive procedures to distend the bladder (Ramsden and others, 1976). However, some enuretics do not display any of the symptoms identified by the biomedical researchers as important. Even if such factors do exist, they might still be responsive to behavioral treatment procedures. For example, bladder-retraining programs do appear to be effective for the so-called unstable bladder (Allen, 1977; Svigos and Matthews, 1977). Much of what has been observed for bladder function and enuresis could be applied to the relationship between colonic function and encopresis. One important difference between bladder and bowel dysfunction is that the problem for the bowel is more likely to be that of retention (and concomitant leakage) rather than sporadic or uncontrolled expulsion (Bellman, 1966; Wright, 1975). Biomedical interventions have typically taken the form of medications and surgery. The use of behavioral procedures appears to be as applicable for encopresis as for enuresis (Butler, 1977; Engel, Nikoomanesh, and Schuster, 1974; Epstein and McCoy, 1977; Halpern, 1977; Kohlenberg, 1973; Wright, 1973,1975). The behavioral research viewpoint on incontinence is represented by Mowrer and Mowrer (1938) in their early conceptualization of nocturnal enuresis as a habit deficiency. That is, incontinence is the result of a failure to utilize the stimuli and responses necessary for accomplishing bowel or bladder control. The Mowrers developed a device that is commonly known today as a bedwetting alarm. It is widely available through the major mail-order houses and medical supply outlets (Collins, 1976). The Mowrers theorized that the bedwetting alarm mediates a classical conditioning process, whereby the pressure cues arising from the bladder, which are still present at the sounding of the alarm, take over in eliciting the awakening and/or sphincter contraction necessary for continence. A reanalysis of the basis for the effectiveness of the bedwetting alarm has been offered from an operant conditioning viewpoint (Azrin, Sneed, and Foxx, 1974). This view emphasizes all the reinforcing consequences that typically follow when one responds to the alarm by awakening and toileting (among them, smaller wet spots and dry nights). Azrin and his colleagues have developed a more elaborate conditioning program to specifically reinforce additional behaviors that should serve to mediate continence through the night. Azrin and Foxx (197 1) had earlier employed operant conditioning techniques for the daytime toilet training of the institutionalized retarded. A popular book for the layman detailing their daytime toileting procedures for normal children, entitled Toilet Training in Less Than a Day, was published in 1974. Wright (1973, 1975) has independently developed similar procedures especially for treating encopresis. Operant conditioning or biofeedback techniques have also been successfully focused on developing the internal biological responses, such as the anal sphincter response, relevant to bowel control (Engel, Nikoomanesh, and Schuster, 1974; Kohlenberg, 1973). Elaboration on Critical Points The biomedical and behavioral theoretical viewpoints are not incompatible or mutually exclusive. The behavioral view simply assumes that, whatever the cause for lacks in awareness and responding appropriate to achieving or maintaining continence, the appropriate learning can take place for an essentially intact system and organism. For the vast majority of cases of urinary incontinence, with the possible exception of the very elderly (Collins and Plaska, 1975), this assumption has been extraordinarily productive (Azrin and Foxx, 1971; Doleys, 1977; Stewart, 1975). The behavioral treatments appear to be both more effective and longer lasting than surgical techniques and medications when applied to the usual childhood cases of urinary incontinence. Combined biomedical and behavioral treatment interventions for urinary incontinence have been extraordinarily rare, though this need not be the case (Collins, 1976). One reason for this state of affairs may be that the behavioral conditioning procedures are effective and basically benign. The combined biomedical-behavioral approach has emerged as more fruitful for the treatment of encopresis. Halpern (1977) and Wright (1973, 1975) have successfully employed a mixture of both conditioning and medications. Engel, Nikoomanesh, and Schuster (1974) have successfully combined surgical and operant conditioning procedures for the treatment of encopresis. Personal Views and Recommendations Encopresis and diurnal enuresis are so manifest and disturbing that they require almost immediate attention. Nocturnal enuresis can be more successfully hidden but is nevertheless so annoying and destructive of family relationships that it should also be treated as soon as possible. Before treatment for enuresis or encopresis is initiated, a physical examination, an intake interview, and a behavioral baseline are necessary. Many physicians prefer to avoid intensive examinations. The findings are usually negative; even if they are positive, a behavioral intervention still may be indicated during or following medical correction. Successful treatments of related conditions-such as diabetes, urinary tract infections, or constipation often do not remove the enuretic or encopretic symptoms. In the intake interview for enuresis, one should obtain information about past and present attempts at treatment; any history of prior continence; presence of diurnal incontinence; and indications of current urgency or excessive frequency of urination, both as to time and place. Because of the importance of parental supervision during treatment, one must also determine the parents' willingness and ability to carry out the treatment. For example, single parents or employed parents often present special problems which may have to be specifically overcome in order for adequate treatment to take place. Some assessment of the parent-parent and parent-child relationships is also germane to successful treatment. Factors concerning the child must also be examined but typically do not play a large role. To assist in evaluating a child, a parent should complete a behavior symptom checklist (Collins, 1973). Care must be taken not to "pathologize," since many apparent signs of subject resistance are merely secondary to the enuresis and readily disappear with firm, supportive intervention. Most children are intellectually capable and willing enough to follow treatment instructions. A behavioral baseline for enuresis should include time and place of accidents, spontaneous arousals in the night to toilet, size of wet spots in the morning, and bladder capacities before bedtime and upon arising in the morning. One all-day recording of toileting frequencies and bladder capacities is also recommended once a week. Continued monitoring of these same variables, whatever the form of treatment, is highly desirable. The intake interview for encopresis is concerned with many of the same factors noted previously for enuresis, except as they involve bowel movements. However, the emotional and interactional conflicts are often more intense and complicated because of the generally greater aversion to fecal incontinence. The subject's reactions to the bathroom and sitting on the toilet should be determined, since they will often have to be specifically dealt with in treatment. Psychoanalytic concerns may have more credibility for this problem area, but again "pathologizing" should be avoided. Because psychological and physiological complications can result if this condition is left untreated, intervention for fecal incontinence is recommended as soon as the child can comprehend and participate in the treatment procedures. Most children can be successfully treated by 3 years of age. The baseline for encopresis requires hourly checks for soiling. The amount, color, and viscosity of the stools should be estimated. The application of any routine aids to promote defecation should be noted. Medical interventions for what appear to be primarily behavioral problems are mainly unwarranted. One exception would be for encopresis, where suppositories are a part of the usual behavioral intervention treatment program (Halpern, 1977; Wright, 1973, 1975). Another exception would be for bedwetting where special circumstances for instance, family vacations-might suggest employing a temporary measure, such as the use of a tricyclic antidepressant. Finally, for adult primary enuretics who have failed to respond to any treatment, a bladder transection to reduce neural innervation of the detrusor might be considered (Essenhigh and Yeates, 1973; Parsons, O'Boyle, and Gibbon, 1977). Once initiated, a behavior modification program requires strict adherence and plenty of support (Collins, 1973). Successful treatment followed by a relapse does not constitute a failure of the original treatment, since anything that is learned is subject to being "forgotten." Typically, relearning proceeds without incident from another course of conditioning. The failure of a conditioning regimen does not appear to have serious consequences and is apparently benign (Collins, 1973). However, successful treatment results in overall better psychological benefits (Doleys, 1977). More heroic medical examination or treatment procedures might well be reserved for use after conditioning interventions have been shown to be unsuccessful for individual cases. Traditional psychotherapeutic procedures are not generally indicated for the treatment of encopresis and enuresis. However, the professional person must remain alert to the employment of the appropriate psychotherapy procedures to deal with the reactive features of incontinence or its treatment. In a relatively small proportion of cases, it may be necessary to intervene with behavior therapy or psychotherapy on a preliminary basis to allow subsequent meaningful behavioral and/or medical interventions. The social and personal costs of allowing enuresis and encopresis to continue unabated are well documented and are to be avoided. Even physical costs become more likely, since there is an increased possibility of bladder infection, bladder trabeculation, and other organic complications if specific treatment is not undertaken (Collins, 1976; Wright, 1973). All these considerations are perhaps most obvious for encopresis and diurnal enuresis and less so for nocturnal enuresis, which can often be successfully hidden. Statements by professionals that a child will simply outgrow his or her incontinence must be regarded as approaching the unethical at this time. This judgment is strengthened by the existence of presently available, relatively inexpensive, and effective treatments for enuresis and encopresis. Application
to Particular Variables Article Truncated Here.
IMPORTANCE
OF THE BLADDER-CUE BUZZER CONTINGENCY IN THE CONDITIONING TREATMENT FOR
ENURESIS (Abstract) Here
is a scientific journal article by this site's owner which got him invited
to Australia as a Distinguished Visiting Professor at the University of
Western Australia near Perth in 1975-1976. The article was an "Active
placebo, double-blind study" which helped to validate the Classical Conditioning
rationale for the effectiveness of the bedwetting alarm. It received
well over 100 citations in the scientific literature. This work
with that of Logan Wright led to the development of my Clean Kid Treatment
methods. CONTRIBUTION
OF BEHAVIOR THERAPY AND BIOFEEDBACK TO LAXATIVE THERAPY: THE TREATMENT
OF PEDIATRIC ENCOPRESIS (Abstract) This
study by Dr. Daniel J.Cox used a combined medical behavioral approach
to the treatment of encopresis. He called his approach Enhanced Toilet
Training (ETT) as contrasted to the usual medical approach which was labeled
Intensive Medical Care (IMU). ETT and a biofeedback condition (BF) were
superior to the usual "biomechanical" medical approach using oral laxatives.
However, he also used oral laxatives so his approach is not directly comparable
to my approach. The Clean Kid Manual avoids oral laxatives and emphasizes
the timing and use of "free" trials, followed by suppository and enema
trials, if necessary, in an escalating fashion until an adequate bowel
movement reliably takes over in association with the natural gastrocolic
reflex following a selected daily meal. The Clean Kid approach results
in a much quicker resolution of soiling accidents. The Clean Kid
approach is less confusing and more obvious because the response is much
more predictable and rapid to a suppository or enema than an oral laxative
which can have very delayed and less predictable effects. However,
the Cox approach does offer an alternative for parents and children who
are very leary and defensive about the use of suppositories or enemas.
His approach demonstrates the power of a systematic and rational behavioral
conditioning approach when combined with the use of oral laxatives. |
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