William J. Warzak

Psychological and psychiatric issues in urinary and fecal incontinence

PURPOSE We provide an overview of the psychological and psychiatric aspects of nocturnal enuresis, urinary and fecal incontinence. Clinical behavioral disorders and subclinical psychological symptoms are reviewed. Aspects of screening, assessment, counseling and in severe cases treatment are outlined, and recommendations are formulated. MATERIALS AND METHODS Relevant publications on psychological and psychiatric aspects are reviewed. The recommendations passed several rounds of consensus finding, and were circulated among International Childrens Continence Society members and external experts. RESULTS In addition to subclinical effects on self-esteem, quality of life and distress, the rate of comorbid clinical behavioral disorders is increased. In fact, 20% to 30% of children with nocturnal enuresis, 20% to 40% with daytime urinary incontinence and 30% to 50% with fecal incontinence fulfill the criteria for ICD-10 or Diagnostic and Statistical Manual of Mental Disorders IV psychiatric disorders. These concomitant disturbances require assessment and counseling, and in severe cases treatment. They have a negative effect on compliance and outcome if not addressed and left untreated. CONCLUSIONS Because the comorbidity rate is high, screening for psychological symptoms is recommended for all children in all settings with enuresis and/or daytime urinary and/or fecal incontinence. Standardized, validated questionnaires are recommended. In addition to clinical observation and history, a short screening questionnaire can be used as a first step. If problem behaviors are present a longer broadband questionnaire is recommended. If problem items in the clinical range are noted, a full child psychiatric or psychological assessment is recommended.

Caffeine Consumption in Young Children

Two hundred twenty-eight surveyed parents reported that their 5 to 7 year old children drank approximately 52 mg of caffeine daily and their 8 to 12 year old children drank 109 mg daily. Caffeine consumption and hours slept were significantly negatively correlated, but caffeine consumption and enuresis were not significantly correlated. Spanish-speaking parents reported fewer bedwetting events than their English-speaking peers.

Toilet training in primary care: current practice and recommendations from behavioral pediatrics.

ABSTRACT. This article is the first to evaluate pediatricians’ (1) current practices regarding recommendations for toilet training typically developing first-time learners and (2) opinions on an intensive procedure for rapid toilet training. Results of surveys obtained from 103 pediatricians indicate that physicians’ recommendations lean toward a gradual, passive approach to toilet training with 72% endorsing “child interest” in the toilet as one of the top criteria children must exhibit before beginning training. Respondents had a somewhat unfavorable view of intensive toilet training for first-time learners with 29% endorsing the use of such a procedure, although in most cases without all of the components. It is recommended that some components of the intensive procedure could easily “fit” with physicians’ current practices to increase toilet-training effectiveness within a shorter training interval. These recommendations, including compliance training as a part of teaching, increased fluid intake to promote toileting trials, and multiple training sits, are described.

Clinical Perspectives in Primary Nocturnal Enuresis

Primary nocturnal enuresis (PNE) is prevalent among the pediatric population, but not all professionals are aware of the current research regarding the etiology and treatment of this disorder. This paper presents a broad overview of PNE, including etiology and evaluation, with a specific emphasis on treatment issues. The most current treatments (imipramine, desmopressin acetate arginine vasopressin, enuresis alarms) are discussed, including recent research on their effectiveness. In considering the recent data on long-term efficacy, overall cost, and safety, the treatment of choice appears to be the enuresis alarm for those families who are capable of following protocols. Desmopressin acetate arginine vasopressin is a safe alternative that has the advantage of quick response and ease of administration.

Coping with Prader-Willi syndrome

Weight- and behavior-control issues are major concerns for parents of a child with Prader-Willi syndrome. However, limited information is available on how families implement the necessary dietary restrictions and the effects of the strategies. This study identified the advice a group of families received regarding weight management, the nutrition concerns they faced and how they coped with these concerns, and the effectiveness of their coping strategies. A 2-step survey methodology was used. Survey 1 identified the strategies parents used to cope with the feeding issues typically presented by children with Prader-Willi syndrome. Survey 2 evaluated the frequency with which these coping strategies were used and their effectiveness. Respondents also provided information on why strategies were not effective. Surveys were mailed to 496 parents/guardians of children (aged 25 years or younger) with Prader-Willi syndrome. A total of 293 (64%) responded. Advice given to families centered on general weight management and dietary guidance. Difficulties centered around coping with food-related behaviors. Coping strategies varied; what worked for 1 family did not necessarly work for another. Participants indicated a desire to share experiences and a need for specific strategies to cope with feeding-behavior difficulties. A few basic behavior-management strategies, including successful use of incentives, responding to misbehavior, rewarding compliance with an exercise program, and modifying the behavior management when indicated, are briefly reviewed.

Current concepts in pediatric primary nocturnal enuresis

It is estimated that enuresis affects 5 to 7 million children in the United States. Although the problem is common and well known, appropriate and effective treatment is not always provided. This may be due to the many etiological theories associated with this condition as well as a correspondingly high number of interventions. The present paper summarizes the empirical literature regarding primary nocturnal enuresis (PNE), with an emphasis on pharmacological and behavioral interventions. The data support the view that children with enuresis have a wide range of negative experiences that can affect self-esteem and development, but that enuresis is not associated with significant psychiatric or behavioral difficulties. Given the strong empirical support for several interventions for PNE, children who have this condition should not go untreated.

Enhancing refusal skills: identifying contexts that place adolescents at risk for unwanted sexual activity

Refusal skills training is one approach to reducing school-age pregnancy and sexually transmitted disease. The generalization of these skills is dependent, in part, on the relevance to participants of the training scenarios. We identified and cross-validated relevant contexts for inclusion in scenarios for refusal skills training. Fifty-six sexually active female adolescents identified 59 contexts associated with unwanted sexual activity. Fifty-one additional subjects rated these on 9-point Likert scales according to how common and difficult each was for them. Unsupervised activity where alcohol is present or feeling an obligation to engage in sexual activity emerged as high risk contexts. The most common and difficult contexts provide points of departure for the development of relevant training scenarios for refusal skills training, thereby contributing to generalization of these skills and reducing the risk of unwanted sexual activity within this population.

Time-Out Training Without Put-Backs, Spanks, or Restraint: A Brief Report of Deferred Time-Out

We demonstrate the effectiveness of a procedure to increase compliance in young children who are resistant to Time-out (TO). Parents of two boys, 3 and 4 years of age, were unable to enforce TO without resorting to physical guidance and restraint. With deferred TO (DTO), if a child resists TO, caregivers no longer interact with the child or provide the child with tangibles or activities that the child cannot access independently. When the child requests a preferred item or activity from the caregiver that cannot be obtained independently, the child must first serve TO. Once TO is served, the caregiver may fulfill the childs request. Data suggest that DTO reduces the latency between the parental TO command and compliance with TO without put-backs, spanks, or restraint.

Central Nervous System Dysfunction

Central Nervous System (CNS) dysfunction, whether the result of acquired injury, congenital defect, or developmental events, can have significant consequences for a child’s psychosocial functioning and classroom performance. The long-term sequelae of CNS insult may impair performance on many levels, with the severity of a student’s limitations being associated with the severity of the neurological insult. This chapter will focus on three types of CNS dysfunction and their implications for the student, school staff and school psychologist. We will provide the reader with a general understanding of the most common consequences of pediatric traumatic brain injury (TBI), postconcussion syndrome, and seizure disorders. Relevant medical management and rehabilitation issues will be presented across all conditions. Pharmacological issues, especially as they pertain to seizures, will be presented because performance in the classroom may be affected by these medications. Behavioral interventions will receive special emphasis. Indeed, behavioral approaches to address CNS dysfunction have become increasingly important and commonplace (see for example, Dahl, 1992; Dahl, Brorson, & Melin, 1992; Fenwick, 1991; Horton & Miller, 1985; Horton & Sautter, 1986; Kuhn, Allen, & Shriver, 1995; Warzak & Kilburn, 1990).

Advancing Continence in Typically Developing Children: Adapting the Procedures of Foxx and Azrin for Primary Care.

Objective: To (1) identify and summarize procedures of Foxx and Azrins classic toilet training protocol that continue to be used in training typically developing children and (2) adapt recent findings with the original Foxx and Azrin procedures to inform practical suggestions for the rapid toilet training of typically developing children in the primary care setting. Method: Literature searches of PsychINFO and MEDLINE databases used the search terms “(toilet* OR potty* AND train*).” Selection criteria were only peer-reviewed experimental articles that evaluated intensive toilet training with typically developing children. Exclusion criteria were (1) nonpeer reviewed research, (2) studies addressing encopresis and/or enuresis, (3) studies excluding typically developing children, and (4) studies evaluating toilet training during infancy. Results: In addition to the study of Foxx and Azrin, only 4 publications met the above criteria. Toilet training procedures from each article were reviewed to determine which toilet training methods were similar to components described by Foxx and Azrin. Common training elements include increasing the frequency of learning opportunities through fluid loading and having differential consequences for being dry versus being wet and for voiding in the toilet versus elsewhere. Conclusion: There is little research on intensive toilet training of typically developing children. Practice sits and positive reinforcement for voids in the toilet are commonplace, consistent with the Foxx and Azrin protocol, whereas positive practice as a corrective procedure for wetting accidents often is omitted. Fluid loading and differential consequences for being dry versus being wet and for voiding in the toilet also are suggested procedures, consistent with the Foxx and Azrin protocol.