TYPICAL AGE AT CONSOLIDATION AND TRENDS

Children in the United States typically become toilet trained between 2 and 3 years of age. At this stage, children are neurologically capable of sensing and containing stool and urine, and they have the language and motor skills to get to the toilet. Over the years, the completion of training has occurred at slightly older ages. Data from the late 1980s revealed that children completed toilet training at an average age of 24 to 27 months.¹ In contrast, in the 1990s, U.S. girls were found to complete toilet training at an average age of 35 months and boys at 39 months.²

Several explanations regarding the phenomenon of later toilet training are proposed. With cheaper, more effective, and larger-sized diapers and training pants, older and larger children can easily use them. Cultural norms and parenting styles have also changed. Years ago, parents were given direct parenting advice, specific instructions about when to put the child to bed, how much to give at each feeding, and when and how to toilet train. Beginning with Dr. Spock in the 1940s, parents have been increasingly encouraged to trust their own instincts when parenting a child, rather than to follow the same uniform directions for every child.³ T. Berry Brazelton expanded this mindset specifically to toilet training.⁴ Endorsing a child-centered approach, Brazelton allowed children to take the lead in the training process. Rather than forcing the child to adhere to an imposed schedule of when to train, parents were encouraged to read a child’s signals that indicated readiness. When children express interest in toileting, have the developmental skills to accomplish the task, and have regularity in stooling and urinating, then parents step in to guide the process. Barton Schmitt later reincorporated specific parent responsibilities in the toilet training process, such as prompting practice runs, responding to successes, and responding to accidents.⁵

The parenting perspective may differ from one cultural group to another. For example, African American parents tend to start training their children at younger ages and are more likely than white parents to agree that it is important for a child to be trained before 24 months.² Not surprisingly, nonwhite children are more likely to be trained earlier than their white peers.²

Blum and colleagues studied a large cohort of children to identify factors associated with later toilet training.⁶ More than 400 children, mostly Caucasian children at the top of the social strata, were monitored. The children who completed toilet training after age 3 years were compared with those who were trained before age 3. Later trainers started training later (at 22.3 vs. 20.6 months), were more likely to be constipated (41.7% vs. 13.2%), and exhibited more stool toileting refusal (56.7% vs. 17.9%) than peers who trained earlier. There were no differences between the two groups in parenting stress, birth order, or daycare participation.

TOILETING READINESS

Several developmental abilities are needed for a child to be toilet trained (Table 24-1). These are referred to as readiness skills. When parents ask when to train the child, it is helpful to provide a checklist of what the child needs to be able to do and an age range in which he or she is expected to do it.

TABLE 24-1 Readiness Skills: Age at Acquisition

The first step in training is the child’s awareness of the sensation of a full bladder or rectum. As the rectum fills, stretch receptors send information to the brain that the stool is accumulating. For urine, a more complex interaction between the bladder and central nervous system is involved. Children often respond to these feelings with withholding behavior. This can be kneeling or freezing to hold in urine or “dancing” to hold in either urine or stool. Even infants have a sense of when they are about to stool, arching or crying in such a way that parents often recognize an imminent bowel movement. Before they are trained to use the toilet, some children hide in a corner or go to a specific room to stool privately. In these cases, the child can sense the urge to defecate.

To train, a child should be dry for 2 hours at a time. This indicates regularity and bladder capacity that are adequate for using the toilet at reasonable intervals without interrupting daily activities. The child must communicate the need to go and his or her desire for access to the toilet. This can be accomplished with words, pointing, or signs. Families should be advised to pick toilet words that are socially acceptable and will be recognized in different settings, such as at school and at friends’ homes. To be independent in toileting, a child must have the motor skills to get to the toilet and must be secure enough to sit comfortably on the toilet or potty chair. Children with neurological deficits may need special apparatus so that they are stable on the toilet. The ability to pull down underpants and pants, including fasteners, is an additional requisite motor skill.

A child cannot urinate or defecate on the toilet without relaxing; physiologically, the child has to relax the buttocks for the stool to be evacuated. The child must then push the stool out or relax the bladder’s external sphincter, followed by wiping and flushing. Children should be taught to wipe from front to back to minimize spread of fecal bacteria.

In many cultures, infants are “trained” to defecate and urinate over the toilet.⁷ This training is behavioral, accomplished by a parent very closely watching the child for signs of imminent voiding, such as a red face, a typical cry, or a typical posture. The parent removes diapers or underwear and holds the infant over a toilet. Infant training necessitates a great deal of consistency from parents and regularity in stooling and urinating patterns in infants. Interest in the US has resurged as “Elimination communication”, considered an extension of parent-child connections and a step toward toilet training. Studies of the benefits, side effects, and long-term outcomes of infant toilet training are not available.

COMMON TOILETING STRATEGIES

In the United States, most children are trained easily and quickly through Brazelton’s child-centered approach. Parents may first buy a potty chair, encouraging the child to pick it to boost excitement and investment. They can place the potty chair in the bathroom, and while parents use the big toilet, the child uses the small one, or pretends to do so. Parents may augment this experience with books and videos about toilet training. When the child is dry for at least 2 hours at a time, he or she may help choose new underwear, often decorated with superheroes or favorite cartoon characters. After stooling or urinating, the child can wear the special new underwear for an hour, successfully experiencing dryness. When parents see signs indicating that the child senses a full bladder or bowel, they can encourage the child to use the toilet. Often they can reward the child with a hug, sticker, or small treat. During the period that children are consolidating continence, they often make a transition from diapers to disposable training pants that can be pulled up and down like underwear.

Another common approach some parents use is to remove diapers or training pants altogether. Children who have the needed readiness skills and an easygoing temperament may do better with this method than do more developmentally impaired children or those with a less easygoing temperament. Parents prepare the child so that over a few days, the child learns to use the toilet. They often may chose a warm summer weekend for the house to become a “diaper-free” zone, when the child wears no diaper or training pant for much of the time. The child and parent stay home, waiting for the urine or stool to come so that the toilet can be used. Initially, they should expect accidents. Some parents increase output by having the child drink more than usual or even eat salty food to create more thirst. Although these techniques are an effective method in many instances, children at risk for physical abuse should not be trained this way, because of the high risk of accidents and often intense nature of this method.

Toilet sitting is another common technique that can be effective. Children are expected to sit on the toilet for 5 minutes at a time, at 2-hour intervals throughout the day and after each meal. Each time, the parent asks the child to try to urinate. When the child sits after meals, the natural gastrocolic reflex makes defecation more likely, and so the child is asked to stool. When bearing down, the child may place his or her hand on the lower abdomen to feel it push out. Parents usually give small rewards at first for trying and later for success. Reading books and singing songs can help make the sitting time pass pleasantly while the expectation is reinforced. Children who are toilet trained at preschool or daycare often learn through this method: they may be taken to the toilets at intervals, when they line up and wait their turns outside the bathroom. Peer activities can be an added incentive to motivate the children.

RELEVANT RESEARCH

There is little research support for a single best, evidence-based method of toilet training a child.⁸ One review concluded that no randomized, controlled studies of preschoolers provide evidence for treating problems related to toilet training.⁹ The largest body of evidence stems from Azrin and Foxx, whose intensive approach breaks training into individual steps and is effective for both developmentally abnormal and typically developing children.¹⁰ Although Brazelton’s child-oriented approach is currently perhaps the most commonly used,¹¹ no outcome data have been published since his original report.

WHAT IS KNOWN ABOUT THIS PROBLEM?

Increasing data are available regarding children who are not able to toilet train or have more trouble than expected. Based on his extensive experience, Schmitt suggested that the most common cause of delayed toilet training is refusal or resistance but also emphasized that these children are often enmeshed in a power struggle with their parents.¹² Schonwald and associates furthered the understanding of difficulty in toilet training by demonstrating these children’s significant tendency to have difficult temperamental traits outside of their toileting difficulties.¹³ Children who were referred to a tertiary care center for failure to toilet train were less easygoing temperamentally and were more likely than easily trained children to have a negative attitude, be poorly adaptable, be less persistent, and be more hesitant in new situations. They were also substantially more constipated than were peers who trained easily. In comparisons of parents of such children with parents of typically trained children, no difference in parenting styles were found. Blum and colleagues confirmed that constipation in children with toilet training difficulty occurs before the toilet refusal¹⁴; theoretically, it hurts the child to stool, and so the temperamentally at-risk child then avoids stooling; this leads to more constipation and pain, and a vicious cycle ensues.

MANAGEMENT OF TOILET REFUSAL

Few interventions regarding late toilet training have been studied.¹⁵ Successes associated with such interventions have been minimal. Taubman and coworkers demonstrated that (1) discouraging negative terms for feces and (2) praising children who defecate into diapers before training began (using a child-oriented approach) did not decrease the incidence of stool toilet refusal but did shorten its duration.¹⁶

Late toilet training interventions must account for the child’s temperament, constipation status, and the parent-child dynamics that often develop around the toilet training power struggle. A group treatment approach has been one effective model that addresses these elements in a 6-week program.¹⁷

THE HIDDEN PROBLEM

Unfortunately, the private nature of toileting and the shame and disgust sometimes associated with defecation make encopresis a challenging disorder to identify. In the pediatric office, a child can demonstrate skills in walking, communicating, and socializing but is not expected to show the doctor his or her toileting skills! On occasion, providers find stool leakage in a child’s underwear on examination, or a particularly stressed or worried parent asks for guidance. In general, the topic of encopresis must be explicitly queried by the provider to elicit the problem. Parents are often too embarrassed to bring up the subject on their own.

Unlike more obvious developmental and behavioral issues, encopresis is not easily discussed among parents. In contrast to children with sleep problems and tantrums, families of children with encopresis have rarely heard of another child with the same problem. Typically, families approach encopresis as a behavior problem, attributing willfulness as the cause. They may associate encopresis with filth, embarrassment, and serious psychiatric pathology, with no understanding of its underlying cause. Although Internet access creates unprecedented opportunities for research about medical conditions in the privacy of a parent’s own home, few parents would know to search “encopresis.”

INCIDENCE HARD TO CONFIRM

It is difficult to determine the true prevalence of encopresis because of its private nature and families’ and children’s reluctance to discuss it. Some authors report that 1% to 3% of children between ages 4 and 11 years suffer from encopresis²⁰ (Table 24-2); similarly, the prevalence of encopresis was 4.1% among 5- to 6-year-olds and 1.6% among 11- to 12-year-olds in a large, population-based study in The Netherlands, with an increased incidence among those with psychosocial problems.²¹

TABLE 24-2 Incidence of Encopresis

EMOTIONAL EFFECT RATHER THAN CAUSE

Traditionally, the perceived association between encopresis and serious emotional problems triggered mental health referrals for children presenting with stool leakage or larger accidents.²² Children with stool accidents are at risk for physical and sexual abuse, perhaps because their accidents trigger anger in uninformed caregivers, although encopresis may also be a physical response to anal trauma.²³ Children who are traumatized can lose continence as a sign of regression, like all other fragile developmental skills that deteriorate in times of stress. Stool incontinence can also be a protection against abuse; a child may discover that stool in the underwear will keep an abuser away. In all cases of children presenting with encopresis, possible abuse must be explored, although it is rarely found.

Children with encopresis can develop emotional problems, which may be a consequence of being teased and embarrassed, leading to poor self-esteem, anxiety, reduced school performance, and impaired social success.²⁴ They may suffer when uneducated families exacerbate their sense of failure, expecting the child to stop the accidents despite his or her inability to control them. However, in most cases, encopresis is not symptomatic of a larger psychiatric problem.²⁵

CONSTIPATION OF VARYING DEGREES

Most children with encopresis are constipated.²⁶ However, mild constipation can lead to overflow incontinence, whereas some severely constipated children have no encopresis. The critical variable seems to be the amount of rectal dilatation, not the absolute amount of stool in the bowel. Historical details elucidate the degree of impaction and dictate the intensity of intervention.

CAUSES OF CONSTIPATION

Constipation is common in U.S. children, affecting 5% of children aged 4 to 11 years.²⁷ In most children, there is no specific abnormality or disease that necessitates treatment. Again, history and physical examination identifies children in need of investigation for a pathological cause of constipation. The symptoms of slow growth, depression, and weight gain and a positive family history are indications for thyroid function testing to assess for hypothyroidism. A thorough physical examination should include an assessment for any signs of neuropathy or myopathy, which could manifest in the gastrointestinal tract with constipation. Conditions such as cerebral palsy or myelomeningocele are frequently associated with chronic constipation. It is also possible on physical examination to detect anatomical abnormalities, such as a very anterior ectopic anus or anal ring stenosis. Although inflammatory bowel disease more commonly manifests with loose stools, constipation is possible, and systemic symptoms, anal tags, weight loss, and a family history of autoimmune disorders may indicate the need for a workup for these conditions. Severe constipation is also possible in celiac disease.

Children with lifelong constipation symptoms may have Hirschsprung disease. They have had difficulty in evacuation from birth with recurrent abdominal distension. They may have frequent emesis and may suffer from failure to thrive and enterocolitis in infancy. Encopresis is rare in children with Hirschsprung disease and is found only in affected children with the rare short-segment form of Hirschsprung disease. In addition to historical information, a tight aganglionic rectum around the examining finger found during rectal examination should raise suspicion. Typically, children with encopresis have either normal rectal examination findings or decreased rectal tone and a palpable stool mass.

Many medications can cause constipation. Several psychoactive treatments can be constipating, such as selective serotonergic reuptake inhibitors, α-adrenergic agents (clonidine, guanfacine), and atypical neuroleptic agents. Anticholinergic medications, such as oxybutynin chloride (used for urinary incontinence), can be constipating as well.

IMPAIRED BOWEL SENSATION AND MUSCULAR STATUS

When encopresis is caused by constipation, impairment of bowel integrity is thought to be the cause. Stool is retained, dilating the rectum and sometimes the sigmoid colon. The bowel wall is stretched by the stool mass, and often the rectum becomes impacted with hard feces. Water is absorbed by the gut wall, and the feces becomes harder the longer they remain in the bowel. The stretched muscle layers lose ability to contract effectively against the large mass, and stool leakage around the stool mass develops.

BODY SIGNALS BECOME INCONSISTENT

When impacted stool blocks the rectum, stretch receptors are thought to lose the ability to sense when the rectal vault becomes filled, as the receptors remain stretched by the abnormally large fecal mass. Theoretically, no signal that the rectum is filling and the external sphincter should be contracted is sent to the brain. Softer stool formed proximally then leaks around or between hardened rocks of stool in the rectum, leaking into underwear without warning. This leakage is the main hallmark of encopresis. Leakage may be liquid or formed, daily or less frequent. Some children have more leakage just before evacuating, which indicates that the rectum has filled, has stretched, and cannot detect and respond to stool reaching the anus. For those children, they may have intact sensation when their rectum is not filled and thus frequently sense the need to defecate, voluntarily contract the external sphincter, and prevent accidents. However, as the impacted stool enlarges, sensation deteriorates, and accidents occur.

HISTORY AND EXAMINATION REGARDING CONSTIPATION AND NEUROLOGICAL PATHOLOGY

The clinician should begin with a detailed history and physical examination, in order to diagnose encopresis and create a treatment plan. The history documentation should include questions about meconium passage after delivery and any early interventions needed for hard, painful stools. Very early symptoms are suggestive of Hirschsprung disease, which usually manifests with difficulty in evacuation from birth. It is helpful to identify any evidence of systemic diseases or medical causes of constipation from the medical and surgical history that indicate treatments other than laxatives and maintenance of stool regularity.

The current history should include the patient’s urinary and bowel patterns, such as frequency of stool evacuation into the toilet, stool accidents, stool consistency, and the urge to defecate. More severe, prolonged constipation usually necessitates more aggressive treatment. A history of abuse or trauma suggests the possibility of an emotional basis for accidents and the need for further psychological assessment. Children may become incontinent in times of stress or as part of regressive behavior, even in the absence of specific sexual or physical abuse.

Abnormal urinary patterns and urine continence can be manifestations of neurological abnormalities underlying both stooling and voiding concerns. Constipation and encopresis also may be associated with urinary tract infections, especially in girls. Even without infection, enuresis can be caused by a dilated rectum pushing on and irritating the bladder, thus causing spasm. The history may reveal that increasing stool backup is associated with urine accidents. Families should be asked to chart defecation and urination into the toilet, accidents, and quality of stooling in order to clarify these temporal relationships.

As part of the developmental history, details of toilet training, when and which methods were used, and successes or failures can be helpful. Some children with stool accidents have never actually been toilet trained. They have never developed the skill to sense impending defecation, hold it in, and then evacuate on the toilet. These children require directed behavioral programming that focuses on identifying the body signal of a distended rectum, maintaining control over the body by contracting the external sphincter, and cooperating with using the toilet. Toilet refusal often leads to constipation as well, and thus treatment to improve bowel regularity and consistency is often needed.

The physical examination of the child with encopresis includes measurement of growth parameters, consideration of any signs of systemic disease, complete neurological examination, and inspection of the anal opening. Anal fissures cause chronic pain with repeated defecation, tags may indicate inflammatory bowel disease, and an absent anal wink or cremasteric reflex in boys raises concerns for a neurological abnormality. A child with an anteriorly placed anus requires referral to a surgeon. The rectal examination can aid in assessing for Hirschsprung disease and may offer information about the extent of rectal impaction to guide treatment. Rectal examination may divulge low anal pressure, which implies external and/or internal sphincter disease. The rectal examination, when performed with the child lying on his or her back in a modified lithotomy position, helps to minimize the patient’s discomfort.

For children with a history of sexual abuse or who are struggling with the first public discussion of this private problem, a rectal examination may be deferred at the first visit, but visualization of the anal area is essential. A digital examination needs to be performed at least once to rule out organic causes of constipation, particularly in children who do not respond well to typical treatment in a timely manner.

RADIOLOGICAL EXAMINATIONS

For most children with encopresis, assessment can be limited to the history and physical examination alone. An abdominal radiograph is a useful adjunct when the history is vague, when the child is uncooperative with examination, or when the family and child would benefit from concrete evidence of constipation. The North American Society for Pediatric Gastroenterology and Nutrition recommends an abdominal film when the child’s constipation history is in doubt, if the child or parent refuses a digital examination, or if the digital examination is to be avoided because of a history of trauma.²⁸ However, a review of 392 studies of the evaluation of children with constipation and encopresis revealed that the evidence of an association between the clinical symptoms of constipation and fecal load on radiographs was in-conclusive.²⁹ Lumbosacral spine films or magnetic resonance imaging (MRI) is indicated when lower extremity neurological examination findings are abnormal or lumbosacral abnormalities are visualized. Children treated for encopresis for prolonged periods without expected improvement may also be considered for lumbosacral MRI in search of tethered cord with unusually silent neurological examination findings.

BEHAVIORAL STRATEGIES

Encopresis treatment begins with demystification of the problem. Most children and their families have never met or heard of other people with this problem, and usually the child has been punished, blamed, or shamed. Explaining the underlying constipation that prevents the child from being able to control the stool accidents is an essential first intervention. Use of pictures or the child’s own abdominal film can help the family understand the degree of impaction and need for stool evacuation.

From the start of treatment, patients and their families should learn that combined medication and behavioral interventions are vital for successful outcomes.³⁰ Because the bowel wall is stretched and cannot send the brain signals for defecation, a schedule for evacuation is necessary until normal feedback systems are restored. Even if the child does not feel the need to defecate, he or she should sit on the toilet and try to evacuate the bowel regularly. Sit-down times can take place 30 minutes after each meal, lasting for 10 minutes each. Most children do not want to sit during school, so the midday sit-down can take place on weekends only. Younger children may benefit from small rewards or treats for cooperating with the sit-down time and trying to defecate. Treats should be small and inexpensive, such as stickers, an extra story at bedtime, or use of a favorite toy. They also may find it helpful to blow up a balloon or place their hand on their lower abdomen and feel their abdomen push outward when bearing down.

Because children with stool accidents often hide dirty underwear and are frequently punished when the underwear is found, an important part of the intervention is to eliminate negative consequences and provide support for the child in coping with the accidents until symptoms resolve. Older children can be offered a bucket with water and bleach (out of the reach of small children) where dirty underwear can be placed discreetly.

MEDICATION FOR CONSTIPATION

In addition to the initial education and demystification, encopresis treatment starts with a bowel cleanout. More aggressive regimens tend to be associated with better results. Children aged 7 years and older usually can be treated with enemas. One effective treatment plan repeats a 3-day cycle consisting of an enema on day 1, a bisacodyl tablet on day 2, and a bisacodyl suppository on day 3; then the cycle is repeated three times, thereby running 12 to 15 days. Several cleanout schedules can be used regularly, including molasses enemas, polyethylene glycol with electrolyte cleanouts, and high doses of polyethylene glycol without electrolytes. No single cleanout method has been demonstrated to be most effective, but a major objective should be to avoid increasing the child’s accident frequency during school hours.

After impacted stool has been evacuated, all treated children require maintenance management, and they usually require more than dietary changes alone. Recurrences of encopresis often develop after initial cleanouts when families and children fail to continue constipation treatment. Daily use of polyethylene glycol without electrolytes, mineral oil, lactulose, milk of magnesia, or methylcellulose (Citrucel®) is generally adequate. Some children need stimulants such as senna or bisacodyl on an intermittent basis as well. Daily toilet sitting after breakfast and dinner, combined with the medication regimen, is essential because by the time the child actually feels the need for a bowel movement, too much stool has reaccumulated in the previously dilated rectum.

RELEVANT RESEARCH OF EFFICACY

One review of 16 randomized or quasi-randomized trials of more than 800 children with encopresis revealed that behavioral intervention plus laxative therapy, rather than either alone, improved fecal continence in children with encopresis.³⁰ Most children treated for encopresis have meaningful improvement, although there are few data to guide prediction. Recovery rates have been reported as 30% to 50% after 1 year and 48% to 75% after 5 years.

SIGNIFICANCE

The achievement of nighttime continence results from a maturing of the urological and neurological systems. Sympathetic stimulation from nerves T11 to L2 induces detrusor muscle relaxation so the bladder can fill, while the internal sphincter muscle (bladder neck) contracts to contain the urine.³¹ Infants have a small bladder that reflexively empties without voluntary control. To empty, parasympathetic fibers from nerves S2 to S4 activate the detrusor muscle to contract, increasing the intravesicular pressure and relaxing the bladder neck. Voluntary control comes from communication between the pontine micturition center and the sacral nerves, allowing voiding to be inhibited. Over the first 2 years of life, bladder capacity increases, along with central nervous system maturity, and thus the child develops greater awareness of bladder filling. Bladder capacity further increases between 2 and 4 years of age, when voluntary control during the day develops.

To maintain nighttime dryness, some children are aroused by a full bladder and wake to void. In most children, the amount of urine produced per hour decreases, and the functional bladder capacity to remain continent during sleep increases. When waking, children produce a large volume of concentrated urine. Nocturnal enuresis can therefore reflect a delay or defect in any of these elements.

INCIDENCE AND RESOLUTION RATE

Most children are continent at night within 2 years of completing daytime toilet training. However, by 7.5 years, 15.5% of children remain wet at night, although only 2.5% wet often enough to meet criteria for enuresis.³² Each year, bedwetting self-resolves in 15% of children,³³ so that 1% to 2% of 15-year-olds remain wet at night.³⁴ For unclear reasons, boys are twice as likely to suffer from this problem.¹⁹ Bedwetting seems to occur with similar prevalence across cultures, ethnicities, and socioeconomic classes.

EFFECT ON CHILDREN AND FAMILIES

Nocturnal enuresis is rarely associated with serious psychiatric disorders.³⁵ However, experiencing the frustration of persistent bedwetting can affect the emotional well-being of affected children. At a minimum, affected children face barriers to activities involving an overnight stay, such as camp, sleepovers, and vacations. Furthermore, affected children have less competence socially, lower school success rates, and higher than expected levels of behavioral problems.³⁶ For example, 50 children with enuresis were compared with children suffering from asthma and heart problems with regard to their attitudes toward their conditions.³⁷ Children with bedwetting had more negative feelings about their condition, more maladaptive coping strategies, and more negative adjustment to the stress bedwetting causes, regardless of the frequency of nighttime accidents and history of treatment failures. Of importance is that positive attitude was correlated with improved response to treatment.

Nighttime bedwetting typically is stressful to families of affected children, particularly when parents are uninformed about the accidental nature of the disorder. Parents of children who wet the bed report significant levels of withdrawn, anxious, and depressed symptoms in their children, which indicates the negative parental perception of these children.³⁵ Traditionally, children with enuresis have been considered at increased risk for child abuse; according to a study of 889 mothers in Turkey, child abuse was reported in 86% of children with enuresis.³⁸

Other studies indicate that children with bedwetting may have a higher incidence of attention-deficit/hyperactivity disorder (ADHD), a finding that matches common clinical experience. In one study of 120 children aged 6 to 12 years who were referred to an incontinence program, 37.5% met criteria for ADHD³⁹; this percentage was far greater than the expected rate of 7.5%.⁴⁰ Similarly, children with ADHD seem to have more voiding dysfunction than do those without ADHD.⁴¹ Furthermore, studies show significantly lower success rates of bedwetting treatment by alarm or medication in children with ADHD than in those without ADHD, perhaps because of the greater difficulty with compliance by children with ADHD.⁴²

CAUSES

The specific cause of enuresis is unknown, although it is thought to be multifactorial. Each affected child may have a single or multiple predisposing factors, which may indicate the most appropriate and successful treatment choice.

DIAGNOSIS

TREATMENT

The treatment of nocturnal enuresis begins with education and demystification. Because of the shame and blame common to families affected by bedwetting, it is important to provide an explanation that the problem is not a voluntary behavior but rather physiological and often genetically mediated. In our clinical experience, this intervention can immediately help to change a family dynamic and a child’s self-concept.

SIGNIFICANCE

Incidence

Daytime continence is achieved in 70% of children by age 3 years and in 90% by age 6 years (Fig. 24-1).⁵⁸ The exceptions raise suspicion for organic pathology, as do cases in which children were previously dry during the day and later suffer from accidents. Daytime incontinence is most commonly caused by treatable or benign conditions, but the rare and potentially serious origins must be investigated. Fortunately, a thorough history, physical examination, and urinalysis are generally adequate diagnostically to identify these conditions.

FIGURE 24-1 Prevalence of daytime wetting by age.

(Adapted from Robson WL: Diurnal enuresis. Pediatr Rev 18:407-12, 1997.)

DIAGNOSIS

TREATMENT