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Elimination Disorders

Created on August 5, 2017. Last updated on February 24th, 2020 at 02:50 pm

Pediatric Elimination Disorders

What is a Pediatric Elimination Disorder?
This diagnostic category encompasses Enuresis and Encopresis. Enuresis is defined as voiding of urine into bed/clothing, in children who are at least five years of age. For the diagnosis to be given, the voiding must occur at least twice per week for at least three months. Enuresis can occur during the day or at night, or both. It is believed that daytime (diurnal) enuresis is different from nocturnal enuresis, in biological pathways and medical comorbidity. Encopresis involves either voluntary or involuntary voiding of the bowels (fecal incontinence) in appropriate places, in children who are at least four years of age (symptoms must persist for at least three months).

Effective Therapies for Pediatric Elimination Disorder

Nocturnal Enuresis

Level One: Works Well ·         Urine alarm

·         Dry-bed training

Level Two: Works ·         Full Spectrum Home Therapy
Level Three: Might Work ·         Lifting
Level Four: Unknown/Untested ·         None
Level Five: Tested and Does Not Work ·         Hypnotherapy

·         Retention control training



Level One: Works Well ·         None
Level Two: Works ·         Biofeedback

·         Enhanced Toilet Training

Level Three: Might Work ·         None
Level Four: Unknown/Untested ·         None
Level Five: Tested and Does Not Work ·         None


Therapies and Terms Defined
Urine alarm therapy involves use of sensors that detect moisture, either worn on the body or placed in a pad that lies atop the mattress. When moisture is detected, the child is alerted (e.g., alarm or tactile) to go use the bathroom. Via behavioral conditioning, the child learns to recognize when the bladder is full before the alarm sounds, thereby eliminating need for continued use of the alarm. This approach has been extensively studied.

Dry-bed training is a multicomponent intervention. Based on operant conditioning principles, this approach pairs the urine alarm with behavioral strategies such as a frequent waking schedule and overcorrection for bedwetting (e.g., child has to change bedding). Dry-bed training is most effective when paired with the urine alarm, as opposed to use in isolation. Likewise, dry-bed training appears to be superior to the urine alarm used alone.

Full Spectrum Home Therapy (FSHT) is a manual-based, multicomponent intervention that utilizes the urine alarm, several behavioral strategies, and graduated over-learning. Over-learning involves drinking increasing amounts of water prior to bedtime. FSHT was designed to be less burdensome on the child and family than dry-bed training (e.g., there is no frequent waking schedule).

Lifting is a Level 3 intervention (see below). Simply, the parent lifts or walks the child to the bathroom to the toilet during the night, then returns him/her to bed. Despite evidence of positive effect, there is some concern about parental burden with this treatment.

Hypnotherapy for enuresis has success rates equivalent to what is seen with spontaneous remission, without treatment (about 16%).

Retention control training involves encouraging the child to postpone urination for as long as possible. The goal is to increase bladder capacity.

Biofeedback for encopresis involves the use of electrodes or balloons, placed in or around the anus, which measure anorectal functioning. The goal is to help patients observe their own muscular contractions on a monitor, to teach them to tighten and relax anorectal muscles on command in order to improve bowel function.

Enhanced Toilet Training (ETT) is a behavior modification approach that utilizes education and training and defection (e.g., breathing techniques, training muscle contraction and relaxation). Contingency-based reward can also be used in ETT.


Source: Shepard, J.A., Poler Jr., J.E., & Grabman, J.H. (2017). Evidence-based psychosocial treatments for pediatric elimination disorders. Journal of Clinical Child and Adolescent Psychology, 46(6), 767-797.


Partner Sites:

Evidence-based Services Committee of Hawaii