E-Book, Englisch, 96 Seiten
Christophersen / Friman Elimination Disorders in Children and Adolescents
1. Auflage 2010
ISBN: 978-1-61334-334-0
Verlag: Hogrefe Publishing
Format: EPUB
Kopierschutz: 6 - ePub Watermark
E-Book, Englisch, 96 Seiten
Reihe: Advances in Psychotherapy - Evidence-Based Practice
ISBN: 978-1-61334-334-0
Verlag: Hogrefe Publishing
Format: EPUB
Kopierschutz: 6 - ePub Watermark
A compact, “how-to” manual on effective, evidence-based treatments for enuresis and encopresis.
The aim of this book is to provide readers with a practical overview of the definitions, characteristics, theories and models, diagnostic and treatment recommendations, and relevant aspects and methods of evidence-based psychosocial treatments for encopresis and enuresis, primarily in children. Although treatments and research for elimination disorders are reviewed in general, particular attention is directed at constipation and encopresis, toileting refusal, and diurnal and nocturnal enuresis due to the high incidence of these conditions in children. Case vignettes, websites, and suggestions for further reading are provided for the interested reader.
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3
Nocturnal Enuresis
3.1 Description
3.1.1 Terminology and Definition
Experts have supplied multiple definitions of enuresis during its history as an affliction of childhood. The term itself, derived from the Greek word ourein, which means to urinate, was first used during the 19th century. For much of the 20th century, experts defined enuresis as the repeated and involuntary release of urine into or onto a location not suited for that purpose in children older than 3 years. This age limit corresponded with the age at which most children were believed to be continent at night (Powell, 1951; Schaefer, 1995). Research on the attainment of continence, however, revealed that this level was set too low (e.g., Berk & Friman, 1990), and the American Psychiatric Association (APA) revised the age limit upwards to 5 years. It also distinguished between primary cases, in which the child has never attained continence, and secondary cases, in which the child attains but fails to sustain continence. The diagnostic criteria for enuresis as described in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) may be found in Table 4. Table 4 DSM-IV Criteria for 307.6 Enuresis Enuresis A. Repeated voiding of urine into bed or clothes (whether voluntary or intentional). B. The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant stress or impairment in a social, academic (occupational) or other important area of functioning. C. Chronological age is at least 5 years (or equivalent developmental level). D. The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation. Specify type Nocturnal Only Diurnal Only Nocturnal and Diurnal Reprinted with permission from the Diagnostic and statistical manual of mental disorders, Fourth Edition (© 1994) American Psychiatric Association. 3.1.2 Epidemiology
As many as 25% of boys and 15% of girls were enuretic at age 6, and as many as 8% of boys and 4% of girls at age 12 Estimates of the prevalence of enuresis vary widely, partly because of the samples used to generate the estimates, and partly because of changing definitions. For example, if the definition extends down to age 3, then estimates of prevalence will be far larger than if it extends only to age 5. Nonetheless, even the most conservative research-based estimates show enuresis to be a very common problem among children. For example, the National Health Examination Survey reported as many as 25% of boys and 15% of girls were enuretic at age 6, with as many as 8% of boys and 4% of girls still enuretic at age 12 (Gross & Dornbusch, 1983; see also Foxman, Valdez, & Brook, 1986). Prevalence studies from outside the United States estimate that at least 7% of all 8-year-old children wet their beds with an approximate two-to-one ratio of boys over girls (Verhulst et al., 1985). Estimates of the percentage of cases that are primary according to the definition given above range from 80% to 90% (e.g., Mellon & Houts, 1995). 3.1.3 Course and Prognosis
Enuresis is a relatively benign condition that resolves in virtually every case, even without treatment The psychological sequalae resulting from the way parents, siblings, teachers, and others respond to enuresis are far more consequential than the enuresis itself One subtle form of punishment is treating enuretic children as if they are qualitatively somehow different from nonenuretic children Although enuresis can impose social and psychological burdens on afflicted children and their families, it is, in itself, a relatively benign condition and one that resolves over time in virtually every case, even without treatment. A 15% spontaneous cure rate is well documented (Forsythe & Redmond, 1974). The most problematic potential physiopathological outcome is urinary tract infection, a rare correlate, and one that is more likely due to improper hygiene in response to incontinence than to the incontinence itself. Of much greater concern are the psychological outcomes that can result from how the enuretic child is treated by important others, most notably by family members, teachers, and peers. Enuresis in the high school years and adulthood exists, but rarely, with the exception of increased incidence at the onset of the geriatric years. Unfortunately, enuretic children who do not receive effective treatment cannot volitionally stop or reduce their accidents: The problem is beyond their control. If the social response to their accidents is punishing in any way, then the children are in effect being punished for a behavior they cannot control. Examples of punishment from parents include reduced privileges, fluid restriction, criticism, corporal punishment, and the promise of unattainable rewards (e.g., the child is promised a bicycle if bedwetting stops). Peers engage in ridicule, rumoring, and ostracism, while teachers often respond to enuresis with criticism, reduced privileges, and drawing social attention to the condition. An example of a more pervasive and more subtle form of punishment is the tendency to treat enuretic children as if they are qualitatively somehow different from nonenuretic children. Thus, although enuresis almost always resolves without treatment, untreated cases can last for 10 or more years. And if, during those years, afflicted children are exposed to direct or indirect punishment, their psychological prognosis could be adversely affected. Most empirical research shows that enuretic children as a group exhibit a slight elevation in other psychological problems, but that only a small minority thereof are significantly impaired (e.g., Friman, Handwerk, Swearer, McGinnis, & Warzak, 1998; Shaffer, Gardner, & Hedge, 1984). Therefore, from the currently reigning biobehavioral perspective on enuresis, the prognosis for enuretic children appears to be quite good with two caveats: (1) all forms of punishment should be prevented or eliminated, and (2) timely and effective treatment must be made available (Friman, 2008). Improvement is reflected in gradual reductions in the volume and frequency of accidents. Severe cases can involve multiple high-volume accidents at night, whereas cases nearing resolution may involve only one or two accidents a month. A few studies suggest that the volume of urine, as indexed by the size of the urine stain, is a more sensitive measure of progress (or lack thereof) toward continence than wet or dry nights as such (Ruckstuhl, 2003). Although children with severe cases can take longer to achieve full continence, no evidence indicates that their prognosis is in any other way problematic. 3.1.4 Differential Diagnosis
The differential diagnosis for enuresis includes multiple true physiopathological conditions that, although not prevalent, may cause primary incontinence in children The differential diagnosis for enuresis includes multiple true physiopathological conditions that, although not prevalent, may cause urinary incontinence in children (e.g., Cohen, 1987; Gross & Dornbusch, 1983). A representative list includes the following: • Urinary obstructions (e.g., bladder stones, pelvic tumors) • Urinary tract infection (more often in girls) • Extreme constipation, megacolon • Diabetes • Seizure disorders • Lower urinary tract obstruction • Neurogenic bladder resulting from myelodysplasia, trauma, or other neurological disorders • Physiological genitourinary abnormalities • Congenital malformation of the urinary tract • Sleep apnea Although all of these medical causes of enuresis have the potential to cause or be complicated by psychological problems, none is a primary psychological concern, nor is any one thereof the primary object of psychological assessment instruments. Additionally, all medical causes of enuresis have a higher probability of leading to serious medical sequelae, if left untreated, than enuresis itself does. For these reasons, and for those reasons described in the assessment section below, we recommend that all enuretic children be evaluated medically before psychological treatment is begun in earnest. Furthermore, although the medical causes include multiple medical specialty concerns, the initial appointment should be with a primary care practitioner who is better trained than a psychologist to determine whether medical specialties may be needed. 3.1.5 Comorbidities
Enuretic children as a group have more psychological problems than children in general; however, this higher rate of problems is not considered clinically significant and it tends to diminish following successful treatment ADHD is the only distinct psychological condition for which persuasive empirical support is available for...
