EXTRA: Toilet Training - listen to a podcast with Kent Grelling Ph.D., formerly from The Hayward Department of Child and Adolescant Psychiatry, discussing toilet training (25 minutes).

Elimination Disorders

There are typically two types of elimination disorders that are first seen in childhood: Enuresis and Encopresis. When a child has Enuresis, they typically will involuntarily (although it may be intentional) urinate in their bed or clothing during the day, nighttime, or a combination of the two. This behavior tends to occur at least twice weekly over a period of 3 months. As a result of these symptoms, the child may experience lower self-esteem, become socially isolated from peers due to being teasing, and experience shame and guilt due to caregivers’ expression of frustration and anger toward the child, and consequently punish them for these behaviors. When a child has Encopresis, they typically will involuntarily (although it may be intentional) release feces onto inappropriate places like clothing or the floor of the home or school. This behavior tends to occur at least once a month for 3 months.

In both of these conditions, it is extremely important to first determine whether or not the behaviors are due to the effects of a substance the child may have ingested or is currently ingesting or due to a medical condition. If your child presents with either the symptoms of Encopresis or Enuresis, please consult with your child’s pediatrician first for a medical evaluation.

Once your child has been medically cleared, there are several useful psychotherapeutic methods that have been found to help some families. Much of the responsibility in these methods falls on the caregiver(s). First it is crucial that the caregiver(s) remains calm and nonjudgmental of their child as they intervene with the problem. Caregivers should not express disappointment or anger toward their child and should remain as emotionally detached with regard to the symptoms when they intervene with their child.

Often caregivers get into a pattern of becoming responsible for their child’s behavior. The child needs to become responsible for their own behavior. They can do this when the caregiver directs them to wash their own clothing or the floor area that has been soiled by either feces or urine. Caregivers should supervise this process without showing any strong emotion to the child and should be as patient as possible. The child needs to be reminded to go to the bathroom and sit on the toilet seat for 5-10 minutes every 2-3 hours and especially within 30 minutes after every meal. They may take some pleasant activity to do while sitting, such as a video game, a book, music, something to draw with, etc. Caregivers should positively reinforce these behaviors, congratulating their child for following the directions appropriately and taking responsibility over their own behavior. These rewards can come in the form of verbal affirmations and/or stickers or points, or any other form your child finds rewarding. The child should also be rewarded for having a “No Accident Day.” This may also be a small reward, such as points or stickers, a small (and inexpensive!) toy, etc. When your child has, for example, a “No Accident Week,” they should earn a larger reward, such as perhaps a meal out, a movie, a new game, etc. When your child has had several weeks of no accidents, caregivers may have a kind of party, where other children are invited. Of course, your child may feel embarrassed if other children know the purpose for the party, so it is perfectly reasonable to advertise the event as just an opportunity for friends to have fun together.

Throughout this challenging process, it is crucial for caregivers to continue to be warm, caring, and accepting of their child, while doing their best to not give more than minimal, emotionally-detached attention to your child’s symptoms. Focusing on your child’s success creates possibilities for future successes.