11. Disorders of childhood Flashcards
Define abnormality in childhood and
adolescence
• Must occur from a developmental lens
– Defining deviation from norms can be complicated given the wide range of “normal” development
• Consider various influences on developmental outcomes
– Within child factors (e.g. temperament; cognitive abilities)
– Interpersonal factors (e.g. relationship stability and quality; peer experiences)
– Contextual factors (e.g. community; opportunities for stimulation and learning; SES)
Developmental Contextualism
how do personal characteristics (such as genetic endowment, physicality, temperament), coalesce with contextual influences (such as familial interactions, institutional structures, historical circumstances) to create individuality?
Developmental Psychopathology
The study of human development and the expression of “psychological disorders” in the context of normal developmental changes
what is developmental psychopathy concerned with?
– Using developmental norms to recognise “abnormality”
– Identifying risk and protective factors for developing psychopathology
– Understanding developmental needs at different points in time and the impact of unmet needs on development
– the impacts of psychopathology on development
– Interested in pathways to psychopathology: Less “What causes conduct disorder?” and more “What initiates and maintains individuals on a probabilistic path to conduct disorder and related outcomes?”
Risk factors
factors related to disordered outcomes –
that increase probabilistic risk.
Protective factors
promote competent development
and buffer the impact of risk processes
How do risk and protective factors affect the individual?
- Can have different impacts on different individuals – the same stressor/risk factor may be extremely potent for one person but not another
- Recall equifinality and multifinality
- The timing of risk and protective factors may also be significant
The significance of relationship
• The interpersonal context is significant in shaping neuronal activation and growth
• Patterns of interpersonal experience build the architecture of the brain
– Hebb’s law - Neurons that fire together, wire together
Relationships are the context for learning about…?
– Emotions
– Regulation
– Safety and predictability
DSM view of childhood disorders
there is a close relationship between presentations in childhood and adulthood
Criticisms of DSM-5 approach to childhood disorders
• DSM 5 identifies some features that may appear differently in children and adolescents
• DSM 5 does not provide much guidance on this
– Limited discussion of models of development
– Up to the clinician to be able to meaningfully apply and understand the individual within the context of development and experience
Categories of childhood disorders
Externalising disorders internalising disorders disorders of basic functions neurodevelopment disorders disorders of care
externalising disorders
- Oppositional Defiant Disorder
* Conduct Disorder
internalising disorders
- Separation Anxiety Disorder
- Selective Mutism
- Phobias
- OCD
- Depression
- Adjustment Disorders
- PTSD
Disorders of Basic Functions
- Sleep Disorders
- Nightmare
- Sleep terrors
- Eating Disorders
- Pica
- ARFID
- Elimination Disorders
- Enuresis
- Encopresis
Neurodevelopmental disorders
- Intellectual Impairment
- Autism Spectrum Disorders
- Attention DeficitHyperactivity Disorder
- Learning Disorders
- Tic Disorders
Disorders of care
- Reactive Attachment Disorder
* Disinhibited Social Engagement Disorders
Core features of externalising disorders
Rule violations are one the core features of
externalizing disorders –
determining the seriousness of rule breaking in externalising disorders
seriousness of rule breaking is considered in terms of frequency, intensity, pervasiveness and developmental norms
when are rule violations more of a problem in externalising disorders?
More of a problem when it is part of a syndrome or cluster of problems, rather than when it is an isolated symptom
Age and rule violating in externalising disorders
Children with externalizing disorders, typically break these rules at a younger age than is expected normally (e.g. primary school student experimenting with
drugs/alcohol )
rule breaking as a distinction between ODD and CD
The severity of the rule breaking is one key distinction between ODD and CD
Anger and aggression as a feature of externalising disorders
• Frequently angry – may be losing temper or becoming aggressive • Physical aggression • Verbal aggression/hostility • Criminal behaviours • Argumentativeness • Intent? - Intentional aggression is often considered to be more indicative of pathology
Oppositional Defiant Disorder Criteria
Angry/irritable mood
vindictiveness
argumentative/defiant behaviour
Angry/Irritable Mood criteria of ODD
- Often loses temper
- Touchy/easily annoyed
- Angry and resentful
argumentative/defiant behaviour criteria of ODD
- Often argues with authority figures or adults
- Actively defies or refuses to comply with requests from adults
- Deliberately annoys others
- Often blames others for mistakes or behaviour
Vindictiveness as a criteria of ODD
Spiteful or vindictive at least twice in 6 months
Conduct Disorder Criteria
aggression to people and animals
deceitfulness and theft
destruction of property
serious rule violations
aggression to people and animals as a criteria for CD
- Bullies, threatens or intimidates
- Initiates physical fights
- Used a weapon
- Cruelty to people
- Cruelty to animals
- Stolen while confronting a victim
- Forced someone into sexual activity
deceitfulness and theft as a criteria for CD
- Broken into someone’s house, building or car
- Lying to obtain goods/favours (conning)
- Stolen without confronting a victim (e.g. shoplifting)
destruction of property as a criteria for CD
- Deliberate fire setting with intent to cause damage
* Destruction of property
serious rule violations as a criteria for CD
- Stays out at night before 13 years of age
- Run away from home overnight
- Often truant from school before age 13
Life course Persistent Antisocial Behaviour
Some view that ODD, CD and Antisocial PD are
expressions of the same behaviour at different stages of development
• Is this too deterministic?
• What impact might this view have on
intervention?
Family adversity risk factors of ODD and CD
– Low income – overcrowding in the home – maternal depression – parental antisocial behaviour – conflict between the parents – removal of the child from the home The risk did not increase substantially when only one risk factor was present, however it increased fourfold when 2 factors were present and further again with more factors
Social/Familial Risk Factors
• 4 Parenting approaches classified based on levels of warmth and discipline
• Children with serious conduct problems more likely to have parents
who are uninvolved/indifferent
Social/Familial Factors from a behavioural perspective
“Negative attention”
– Negative attention (e.g. being in trouble) is better than no attention
– Reinforced for doing the wrong thing – positive reinforcement (attention) increases likelihood of future misbehaviour
Social/Familial Factors from a relational perspective
– Replace “attention-seeking” with “connection-seeking”
– Children are reliant on parents to have their needs met
– If they are unable to connect and receive warmth, care and affection (an essential need), they will seek it out some form of response
Inconsistent expectations as a risk factor of ODD and CD
- Unpredictability in expectations of behaviour and discipline
- Frequent rule changes
- Differences in expectations between caregivers/contexts
- One caregiver may undermine the other (sometimes inadvertently)
Angry or aggressive punishment as a risk factor for ODD and CD
- Physical punishment
- Threat based parenting
- Use of hostility and anger to control
Relational risk factors
• Attachment insecurity and disorganisation in early childhood predict behaviour problems in later childhood and adolescence
• Attachment disorganisation is associated with highest levels of externalising problems (Lecompte & Moss, 2014; Dubois-Comtois, Moss, Cyr & Pascuzzo, 2013)
– Particularly controlling-punitive pattern of disorganisation
Social-cognitive processing biases as a risk factor of ODD and CD
– Children who are exposed to violence, hostility and anger learn to expect violence
– Hostile attribution bias – perceive others are likely to use violence/aggression
– leads to greater tendency to demonstrate aggressive behaviour
– An adaptive response when living in a threatening environment but maladaptive when there is no threat
Behavioural Family Therapy as treatment for ODD
– Goal is to move towards Authoritative parenting
– Teaches parents to be very clear and specific about behavioural expectations, monitor children’s actions closely, and systematically rewarding positive behaviours while ignoring or mildly punishing poor behaviour
– Punishment strategies should be firm but not angry, and rewards should far outweigh punishment
– Should also emphasise warmth, positive connectedness, shared time
effectiveness of BFT treatments for ODD
Research supports the short term effectiveness but long term outcomes are less certain and benefits are usually limited to those under the age of 12
– Parents are often stressed and live in adverse circumstances making it harder to implement
– BFT is less effective when parents are unhappily married, depressed, substance abusers, harsh/ critical with their children
– Treatment is more effective when parents get help to cope with their own stress
Attachment focused interventions as treatment for ODD
- Not typically studied in terms of particular disorders but results measured in terms of attachment security
- Relational focus – the caregiver-child relationship becomes the client
- Understanding the central dyadic problem
- Focus on promoting securogenic interactions between parent and child
- Increase the parent’s understanding of the child’s behaviour, and what they are communicating in terms of their needs
- Increase parent’s capacity to see and respond to these needs
- Increase parent’s awareness of how their own mental states/experiences impact their responses
- Reduce the reactivity to these states
- Many different models employ these princip
Multisystemic therapy as treatment for CD
– An intensive family and community based treatment
– Availability of staff 24/7 – intensive sessions, high frequency (often daily)
– Coordination between systems (e.g. justice, education, mental health)
– Target multiple factors contributing to the problem
• Housing
• Employment
• Schooling
• Parenting factors
• Mental health
Internalising Disorders
- Characterised by fears, anxiety, sadness and social withdrawal
- DSM 5 does not separate these out
Identification of Depression in Childhood/Adolescence
Can be hard to identify – adults seem to systematically underestimate the experience of depression among children and adolescents
• May appear as social withdrawal, statements about self worth, somatic complaints, irritability
Criteria for Depression in childhood/adolescence
– In children and adolescents, “depressed mood” can be an irritable mood.
– Failure to make expected weight gain can be considered as indicative of weight loss/change in appetite
The effect of parent’s depression on child prevalence
No correlation between parents’ and children’s’ ratings on a measure of depression (Kazdin, French & Unis, 1983)
– Children’s ratings usually characterized internal hopelessness, low self-esteem and internal attributions of negative events, whereas parents described external behaviour problems and disruption
Rates of Depression in childhood/adolescence
- Rates of depression increase dramatically in adolescence
- 35% of young women and 19% of young men suffer from at least 1 major depressive episode before age 19
- Up to 30% have some elevated depressive symptomatology at any time – may be subclinical, but increases risk for future episodes
Familial risk factors of Depression in childhood/adolescence
– Changes in family environment – separation, relocation
– Family stressors – e.g. Domestic violence/conflict
– Negative life events
– Parent-child conflict
Systemic/sociocultural risk factors o fDepression in childhood/adolescence
– Bullying/marginalisation
– Social isolation/low connectedness (e.g. to school/peers)
– Adolescence onwards - greater level of depression in girls
– Higher rates among indigenous teenagers.
– Higher in low SES areas.
Psychological risk factors of Depression in childhood/adolescence
- Low worth/feelings of inadequacy – may result from social comparison, feelings of academic incompetence
- Loneliness/isolation
- Attributional styles
- Sense of low efficacy, low control, helplessness
Psychotherapy as treatment of depression in childhood/adolescence
depending on the age of the child, this may be one-on-one but generally involves the parents/family
– Treatment depends on the assessment and formulation of contributing factors and the specific symptoms
SSRIs (selective serotonin reuptake inhibitors) as treatment for depression in childhood/adolescence
usually not before adolescence
– More commonly prescribed where neurovegetative symptoms (e.g. Changes in sleep/appetite/weight) or suicidality are prominent
– The FDA has noted an increased risk of suicidal ideation in young people with SSRIs – important to monitor risk during initiation of the medication
– More adolescents have reductions in suicidality than an increase but it’s impossible to know before commencing the medication
– There is great caution around prescribing to children and adolescents
Anxiety in childhood/adolescence
As with adults, anxiety is a normal experience in children
and adolescence
Developmentally appropriate anxiety
– Worries are occasional and transient
– Does not interfere with functioning
– Can be soothed and contained with support
identifiers of Anxiety disorders in childhood/adolescence
– Out of proportion to the threat (given the developmental level)
– Impacting on functioning
– Uncontrollable
– Persistent
Symptoms of Anxiety disorders in childhood/adolescence
Presentations are varied – symptoms may emerge as – Somatic – (e.g. tummy aches) – Perfectionistic/rigidity/control (e.g. with school work) – Tearful/upset easily – Avoidance – Aggression/anger/acting out
Normative Progression of Fears in infancy
stranger anxiety, clinging to parents when confronted by people they don’t recognize.
Normative Progression of Fears in 10-18 months
Separation anxiety, things like loud noises, the toilet, the bath plug hole can be a source of fear
Normative Progression of Fears in 4-6 years
fears about things that aren’t based in reality: monsters and ghosts. dark, scary, noises, masks, animals, witches.
Normative Progression of Fears in 7-12 years
: fears that reflect real circumstances that may happen, such as bodily injury, natural disaster (bushfires/storms), getting lost, fear of dogs, thunder, burglary, parents’ dying. Social anxiety/performance anxiety emerges
Social Anxiety in childhood/adolescence
- Often emerges in late childhood/adolescence – in line with development of capacities for social comparison
- Same criteria as in adults
- The fear of negative evaluation may not be able to be articulated by children/adolescents
- Important to consider functional impact
common themes of Social Anxiety in childhood/adolescence
– Performance anxiety – public speaking, test taking
– Negative evaluation – may manifest as avoidance of eating in public, speaking to strangers/adults
– Emitophobia
Separation Anxiety in childhood/adolescence
- Distress following or in anticipation of separation from a caregiver
- Emerges at around 8 months (coincides with object permanence)
- Normal to see protest, clinging, distress and despair in response to separation from primary caregiver
Age of peak of Separation Anxiety in childhood/adolescence
Typically persists and peaks at around 15 months and slowlydiminishes
when does Separation Anxiety in childhood/adolescence occur in toddlers
Toddlers will typically experience separation distress in unfamiliar environments
reemergence of separation anxiety in older children
Anxiety may re-emerge in older children following changes/disruptions, major life events and persist for a short time after
When is SAD considered abnormal?
Considered abnormal when persists beyond toddlerhood and is
– Persistent
– Pervasive – e.g. unable to be in separate room to caregiver
– Impacts on sleep
– Leads to school refusal or avoidance of other important tasks/contexts
– Accompanied by high levels of distress
Separation Anxiety Disorder - DSM 5 Criteria
Developmentally inappropriate and excessive fear/anxiety about separation from attachment figures
• Persistent fear of separation – distress, protest, clinging, crying, complaints of illness/nausea
• Worries about parents’ dying, becoming ill, being harmed
• Worries about harm to self that may result in separation – kidnapping, getting lost, illness
• Avoidance of separation, leaving home, going on holiday, going to
school
• Unable to sleep away from caregiver
• Nightmares with themes of separation
Determine possible contributors of SAD
- Fear about parent’s consistency and availability
- Fear about parent’s safety or health
- Fears about world/capacity to cope
- Low confidence in own independent capacities
treatment of SAD
- Increase child’s confidence in parent’s stability and availability – change caregiver behaviours and response
- Gradual safe experience of separation
Parents are coaches and models for their children as treatment for anxiety in childhood
– Approach vs. avoidance
– Modeling distress tolerance
– Parents as sources of soothing and regulation – co-regulation leading to selfregulation
Balancing support with gentle encouragement to face anxiety as treatment for anxiety in childhood
– Building resources – relaxation and soothing
– Creating safe opportunities to practice managing anxiety within a tolerable level
– Balancing reduction of accommodation while tolerating the child’s distress
– Reducing criticism
– Not dismissing reality of the fear but also not buying into it
Symptoms of Inattention
(6+ of the following symptoms)
Often makes careless mistakes in school work
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
Often loses things necessary for tasks or activities
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Symptoms of Hyperactivity/
Impulsivity
(6+ of the following symptoms)
Often fidgets with or taps hands or feet or squirms in seat.
Often leaves seat in situations when remaining seated is expected
Often runs about or climbs in situations where it is inappropriate.
Often unable to play or engage in leisure activities quietly.
Is often “on the go,” acting as if “driven by a motor”
Often talks excessively.
Often blurts out an answer before a question has been completed
Often has difficulty waiting his or her turn
ADHD Diagnostic Specifiers
Combined
Inattentive
Hyperactive/Impulsive
Combined Diagnostic Specifiers of aDHD
criteria for both inattention and hyperactivity/impulsivity are met
ADHD requirements
Hyperactivity/ Impulsivity
AND/OR
Inattention
Inattentive Diagnostic Specifiers of aDHD
criteria for inattention only are met
Hyperactive/Impulsive Diagnostic Specifiers of aDHD
criteria for hyperactivity/impulsivity only are met
Mild ADHD
Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
moderate ADHD
Symptoms or functional impairment between “mild” and “severe” are present.
severe ADHD
Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.
Other clinical features of ADHD
- Poor time estimation
- Poor planning skills
- Difficulty internalizing routines, skills and rules
- Delay in motor development and clumsiness
- Low frustration tolerance and anger
- Frequently in trouble for misbehaviour, impulsive decisions
- Can be misunderstood
Comorbidity of ADHD
Co-morbidities seem to be a rule rather than an exception • Learning difficulties • Language difficulties • Motor difficulties • Tourette’s syndrome • Anxiety disorder • Obsessive Compulsive Disorder • ASD • Oppositional Defiant Disorder • Conduct Disorder
diagnosing ADHD
- Formal diagnosis is not normally made until early school years (age 6 or 7)
- Attentional problems, impulsivity and hyperactivity are usually evident earlier than this
- May not be disruptive/impairing until the child enters the school environment
Neurological soft signs as causes of ADHD
other neurological delays often seen in children with ADHD
– For example
• poor fine motor coordination
• Delays in reaching developmental milestones
• Executive dysfunctions
Genetics as a cause of ADHD
– Genetic factors explain 90% of the variance in ADHD symptoms
– Concordance in MZ twins is 80%, compared to 40% in DZ twins
Social/Familial factors of ADHD
- Less evidence for social factors in the aetiology of ADHD than other disorders of behaviour (e.g. ODD and CD)
- But responses of caregivers and teachers can impact on ADHD symptoms both positively and negatively
Responding to symptoms of ADHD
Symptoms of ADHD can be very difficult to respond to
– Increased stress, frustration and attempts to control are common
– May be perceived as intentional or possible for the child to control
– Perception of the symptoms is also important – negative attributions about the child may develop
Stimulant medications and psychopharmacological treatments for ADHD
– psychostimulants (e.g. Methylphenidate (Ritalin)
or Dexamphetamine)
– Have a paradoxical effect on those with ADHD – increases concentration and alertness, enable attention to be narrowed
effectiveness of stimulant medications as treatment for ADHD
- Numerous double blind, placebo controlled studies show that the drugs increase attention/concentration and decrease hyperactivity
- Decreased behavioural difficulties in classroom and at home
- BUT these do not seem to translate into improvements in academic functioning
Common side effects of psychostimulants as treatment for ADHD
– Decreased appetite, increased heart rate, sleeping difficulties
– Increased motor tics in a small number of cases
– May also slow physical growth, typically due to appetite suppression
Behavioural/environmental interventions as treatment for ADHD
• Increased structure
• Use of external aids and prompts
• Frequent reminders and cues
• Repetition of instructions
• Chunking information
• Teacher training to promote understanding and facilitate environmental changes
• Variation in didactic material (i.e., accommodate to the disorder)
• Assessing and addressing comorbid issues – e.g. Learning
difficulties, speech and language problems, motor problems
Intellectual Disability in childhood
• Deficits in intellectual function on standardised measures of intelligence and evident clinically AND
• Deficits in adaptive functioning, including
– Conceptual skills – capacity for self sufficiency, decision making, judgment and problem solving
– Social skills – understanding social rules
– Practical skills – activities of daily living (e.g. Self care)
Age of onset for intellectual disabilities in childhood
Onset of intellectual and adaptive deficits during the “developmental period” - childhood and adolescence
Causes of Intellectual Disability
• There are over 250 known biological causes
– Chromosomal Disorders (e.g. Down Syndrome)
– Genetic Disorders (e.g. Fragile X Syndrome)
– Infections during pregnancy (e.g. Rubella, toxoplasmosis)
– Toxins (e.g. Foetal Alcohol Spectrum Disorders)
– Hypoxic brain injury at birth
• ? Extreme deprivation in early life - impoverished environment – lack of stimulation and responsiveness
Autism Spectrum Disorders
- A spectrum of related disorders
- Not a discrete/singular condition - now seen as a name encapsulating many associated conditions
- Greater recognition of variance in severity and impact
core features of autism spectrum disorder
deficits in social communication and interaction, present from early life
Core criteria of autism
Deficits in social communication and interaction Restricted, repetitive patterns of behaviour, interests or activities
Deficits in social communication and interaction Restricted, repetitive patterns of behaviour, interests or activities
- Repetitive movements or speech
- Insistence on sameness
- Inflexible adherence to routines
- Restricted fixated interests
- Hyper/Hypo-reactivity to sensory input
deficits in social communication and interaction, present from early life
• Social emotionalreciprocity
• Non-verbal
communication
• Developing and maintaining relationships
Social Communication Deficits as a symptom of Autism
Ranges from total absence of verbal and non-verbal communication to
normal language with odd body language & speech patterns
– Delayed speech
– Dysprosody in speech – rate, rhythm and intonation
– Echolalia – repetitive language
– Impairment in use of multiple non-verbal behaviours – eg. eye to eye gaze, facial expression, body postures & gestures to regulate social interaction
– Language difficulties – understanding directions/jokes/questions
Limited social reciprocity as a social commnication deficit
– Difficulty with back and forth conversation/following conversation
– Lack of response
– Lack of spontaneously seeking to share enjoyment (lack of showing, bringing, pointing out objects)
– Failure to develop peer relationships appropriate to developmental level
Restricted, Repetitive Behaviour/Interests as a symptom of autism
• Preoccupation with one or more stereotyped & restricted
patterns of interest – abnormal in intensity or focus
• Inflexible adherence to specific, non-functional routines or
rituals
– Not just a preference
– Become highly anxious & upset if routine/ritual disrupted.
• Repetitive motor mannerisms (e.g. hand flapping, finger twisting,
jumping/pacing, complex whole-body movements)
• Can become self-injurious
• Persistent preoccupation with parts of objects
• Sensitive to sensory input texture of foods, feeling of clothing (may be
painful/irritating), haircuts as painful
• High distress to sounds that others may tolerate as background noise (e.g.
supermarket)
Anxiety as an associated feature of autism
(studies range from 10-80%) – e.g. new experiences/places/routines; loud noises; animals & babies; doctors/dentist/hairdressers/school/toilet; expectations/demands, sensory overload
Challenging behaviours as an associated feature of autism
occur in other disabilities but prevalent in ASD & exacerbated by social/communication difficulties & rigid behaviour - e.g. self-injurious behaviour, aggression to others or environment, stereotypical behaviour.
Sensory sensitivities as an associated feature of autism
– e.g. under or over-arousal (seek out or avoid certain smells/textures/lights/reflections difficulty ignoring irrelevant background noises; lack of or over-reaction to pain; little body awareness).
Learning disorders & intellectual impairment - as an associated feature of autism
ranging from profound intellectual impairment to above average intelligence
– Earlier studies suggested that up to 75% of people with ASD had intellectual disability
– As concept of ASD have progressed and definitions evolved, there is more evidence of ASDs across all levels of intellectual function
– But IQ assessments can be confounded by language which is often impacted in autism
– IQ profiles may be
ASD Severity classifications
- Level 3: Requiring very substantial support
- Level 2: Requiring Substantial Support
- Level 1: Requiring Support
Asperger’s Syndrome no longer included in
DSM
psychological/social causes of ASD
• Does not seem to have any psychological/social causes
– Historical claim that autism resulted from “refrigerator parents” has been discredited
MMR vaccines as a cause of ASD
Feared link between MMR vaccines and autism does not have any scientific support
Genetic causes of ASD
Genetics play a significant role – high concordance rates between MZ twins (60%) compared to DZ twins (0%) Bailey et al. 1995
neurological causes of ASD
evidence of differences in functioning of mirror neurons, and in subcortical brain regions
Medications as treatment of ASD
No medications to treat ASD, but are sometimes prescribed to assist
with some symptoms
– SSRIs may be prescribed and can assist with stereotyped behaviours
– Risperidone (an antipsychotic) may be prescribed to regulate
behaviour
– Controversial due to side effects
Applied Behaviour Analysis as treatment for ASD
intensive behavioural therapy
targeting specific behaviours
family and friend treatments of ASD
- Families find problem solving/adaptations to be very helpful – use of pictures/iPad apps to communicate
- Emotional support for parents and families
Enuresis
Enuresis – wetting – voiding urine with no medical cause
At least twice a week for 3 months after age 5
nocturnal enuresis
during sleep
Diurnal enuresis
during waking outs
Commonality of nocturnal anuresis
Nocturnal enuresis is very common in early and middle childhood
– At age 10 – 10% of children
– At 15 – 3% of children
treatment for enuresis
Can be effectively treated with various biofeedback devices – bell and pad that awakens the child when they begin to wet the bed – 75% effective
• In some cases of older children, a medication is used
Encopresis
• Soiling
• Less common than enuresis
• Nearly all children who soil are, or have been constipated
• Constipation contributes to
– Stretching of colon leading to reduced sensation/urge
– Fear of toileting
– Fear of pain
• May be short term, resolving with treatment for constipation
• Typically causes of not a reaction to psychological distress
