Eating disorders: psychiatric aspects
Eating disorders are among the most common psychiatric disorders and are associated with numerous somatic…
What is enuresis
Enuresis is wetting the bed involuntarily and repeatedly during sleep after the age of five, when most children achieve full control. Diurnal enuresis as a name for the problem has been avoided lately and involuntary urinating during the day is named daytime incontinence. Nocturnal enuresis is diagnosed if involuntary bed wetting appears two or more times per week during a longer period of time, i.e. at least for several months.
There is primary and secondary enuresis. Primary or persistent enuresis is when the child has not achieved control over nocturnal bed wetting, while secondary or regressive nocturnal bed wetting is when control had already been acquired.
Causes and treatment of enuresis
It is important to distinguish between the two since causes and approaches to their treatment are different. Causes of nocturnal bed wetting may be manifold and an overlapping of several factors is often mentioned. In families with children with enuresis we often find individuals who had similar difficulties which indicates the influence of heredity in the aetiology of enuresis. It is also important to exclude organic causes, diseases which result in bladder control difficulties. However, not rarely, and especially in secondary enuresis, we find that the child has been exposed to stressful circumstances in the family or in the wider surroundings. Some of them are changes in family functioning, the birth of a younger family member, moving house, change of kindergarten or school, hospitalisation, parental conflict, difficulties in relationships with peers, overload with school obligations, parental divorce, exposure to violence, and similar.
Although symptoms in most children vanish at puberty, it is not recommended to let it happen spontaneously. It is appropriate to consult medical doctors and, especially in cases where underlying medical condition has been excluded, mental health professionals – psychologists and psychiatrists.
What can parents do
Parents can help their child, too. It is important to understand that the child is not happy about what is happening. S/he may be afraid of peers’ reactions, especially in the situations like school trips and excursions, so it is important to talk openly about the difficulties and, together with the child, develop strategies for coping with certain situations.
It is good to talk with professionals at school or kindergarten about the child’s difficulty. Understanding that it is something the child does not do voluntarily is of utmost importance. Punishing and humiliating the child should be avoided at all times. Awakening the child at night, especially several times during night and caring him/her half-asleep to the toilette should be avoided, too, because it does not connect the child with caring about going to the toilette.
There are procedures evolved from psychotherapeutic approaches, e.g. the technique of rewarding the child with stickers so that the behaviour which we want to reinforce is rewarded. The child can draw a calendar and then draw signs for “dry nights” in it. Symbolic reward is negotiated in advance for e.g. collected four smileys. There are alarm devices which activate in contact with wet bed sheets and that is the way to reinforce the relation between awakening and urinating.
Parents may reconsider unfavourable conditions which may have influence on the child and the family, seek to provide stability, routine, enough pleasant experiences, encourage play and motor activities with the aim of relaxation and seek to ensure time for family activities.
Panic and exaggerated family preoccupation with the child’s nocturnal bed wetting should be avoided by all means, since nocturnal enuresis is not dangerous for the child and the majority of children spontaneously acquire control over their urinating before adolescence.
What is encopresis
Encopresis is leaking stool which is uncontrolled or, in other words, a disorder in emptying stool from the colon so that the child does it at inappropriate places. Similar as in enuresis, the criterion for diagnosing is age, i.e. it is necessary that the child is older than four when most children are expected to have achieved sphincters control. There is also primary and secondary encopresis and it is important to exclude an underlying medical condition. Encopresis is often followed by constipation, or stool holding when liquid stool can leak around the impacted stool and out of the anus. The child may associate the pain due to constipation with going to the toilette and thus avoid going to the toilette.
Causes and treatment
If we have excluded organic causes, psychological ones need to be considered. They may be a bit simpler, like feeling uneasy when using public, school and kindergarten toilettes, avoiding to interrupt the play with peers being the reason why the child does not manage to get to the toilette on time. However, it is more often about more complex psychological causes, personality regression being a bit deeper than in the case of enuresis. So, the difficulties may be a response to changes in the environment, relationships with carers, stressful situations in the kindergarten and school as well as a sign of protest against the imposed demands or a way of “getting parents for oneself”. It is not rare to appear in families where parents attribute too much importance to their child’s acquiring control over stool, being over-caring or authoritative.
It the case of encopresis it is also important to seek professional advice. It may be a psychologist or a psychiatrist, and the advice parents should follow is similar to that in the case of difficulties in urinating control.
Avoid criticism and contempt, think about stressors in the surroundings and your child’s needs, provide sufficient time for family activities which are not exclusively focused on toilette training.