Special Needs

ELIMINATION DISORDERS

Functional Encopresis

The essential feature of this disorder is repeated involuntary (or, much more rarely, intentional) passage of feces into places not appropriate for that purpose (e.g., clothing or floor). In order to make the diagnosis, the event must occur at least once a month (or at least six months, the chronologic and mental age of the child must be at least four years, and physical disorders that can cause fecal incontinence, such as aganglionlc megacolon, must be ruled out.

The stool may be of normal or near-normal consistency, or liquid, as in the case of overflow incontinence secondary to functional fecal retention. When the passage of feces is involuntary rather than intentional, it is often related to constipation, impaction, or retention with subsequent overflow. The constipation may develop because the child, for psychological reasons, avoids defecating, because of either anxiety about defecating in a particular place or a more general pattern of oppositional behavior. In other children, the constipation develops for physiologic reasons, such as dehydration associated with a febrile illness or medication. Once conitipation has developed, it may be complicated by an anal fissure, painful defecation, and further fecal retention.
Functional Encopresis is generally referred to as primary if it has not been preceded by a period of fecal continence lasting at least one year, and secondary if it has been preceded by a period of fecal continence lasting at least one year.

Associated features. Very often the child feels ashamed or embarrassed, and may wish to avoid situations that might lead to embarrassment, such as camp or even school. When the incontinence is clearly deliberate, antisocial and other psychopathological features are common. Smearing feces may be deliberate, and should be differentiated from smearing that takes place accidentally in the child's attempt to clear or hide feces passed involuntarily. Twenty-five percent of children with Functional Encopresis also have Functional Enuresis.

Course. Functional Encopresis rarely becomes chronic, but unless treated, can persist for years.

Age at onset. By definition, primary Functional Encopresis begins by age four. Secondary Functional Encopresis usually begins between the ages of four and eight.

Impairment. The amount of impairment directly attributable to the disorder is primarily a function of the effect on the child's self-esteem; the degree of social ostracism by peers; and anger, punishment, and rejection on the part of caretakers.

Complications. None.

Predisposing factors. inadequate, inconsistent toilet training and psychosocial stress, such as entering school and the birth of a sibling, may be predisposing factors.

Prevalence. it is estimated that approximately 1 % of five-year-olds have the disorder. Primary Functional Encopresis apparently is more common in lower socioeconomic classes.

Sex ratio. The disorder is more common in males than in females.

Familial pattern. No information.

Differential diagnosis. Functional Encopresis must be differentiated from structural organic causes of Encopresis, such as aganglionic megacolon, which need to be ruled out by physical examination and laboratory procedures.


Diagnostic Criteria for Functional Encopresis

A. Repeated passage of feces into places not appropriate for that purpose (e.g., clothing, floor), whether involuntary or intentional. (The disorder may be overflow incontinence secondary to functional fecal retention.)

B. At least one such event a month for at least six months.

C. Chronologic and mental age, at least four years.

D. Not due to a physical disorder, such as agalgIionic megacolon.

Specify primary or secondary type.
Primary type: the disturbance was not preceded by a period of fecal continence lasting at least one year.

Secondary type: the disturbance was preceded by a period of fecal continence lasting at least one year.


Functional Enuresis

The essential feature of this disorder is repeated involuntary or intentional voiding of urine during the day or at night into bed or clothes, after an age at which continence is expected. In order to make the diagnosis, etiologic physical disorders must be ruled out. The disorder is somewhat arbitrarily defined by at least two such events per month for children between the ages of five and six, and at least once a month for older children.
Functional Enuresis is often referred to as primary if it has not been preceded by a period of urinary continence lasting at least one year, and secondary if it has been preceded by a period of urinary continence lasting at least one year. Either of the above types may be nocturnal (most common), defined as the passage of urine during sleep time only, diurnal, defined as the passage of urine during waking hours, or both diurnal and nocturnal.
In most cases of nocturnal Functional Enuresis, the child awakens with no memory of a dream and no memory of having urinated. Typically the disturbance occurs during the first third of the night. In a few cases the voiding takes place during the rapid eye movement (REM) stage of sleep, and in such cases the child may recall a dream that involved the act of urinating.

Associated features. Although the great majority of children with Functional Enuresis do not have a coexisting mental disorders; the prevalence of coexisting mental disorders is greater in those with Functional Enuresis than in the general population. Functional Encopresis, Sleepwalking Disorder, and Sleep Terror Disorder may also be present.

Course. Most children with the disorder become continent by adolescence, but in approximately I % of cases, the disorder continues into adulthood.

Age at onset. Primary Functional Enuresis by definition begins by age five. In most cases of secondary Functional Enuresis, onset is between the ages of five and eight.

Impairment. The amount of impairment directly attributable to the disorder is primarily a function of the effect on the child's self-esteem; the degree of social ostracism by peers; and anger, punishment, and rejection on the part of caretakers.

Complications. None.

Predisposing factors. Among predisposing factors are delay in the development of the supporting musculature of the bladder, and impaired ability of the bladder to adapt to urinary filling without changes in intravesical pressure, resulting in a lower bladder volume threshold for involuntary voiding; delayed or lax toilet training; and psychosocial stress, in particular, hospitalization between the ages of two and four, entering school, and the birth of a sibling.

Prevalence and sex ratio. The prevalence of Functional Enuresis as defined here is: at age 5, 7% for males, and 3% for females; at age 10, 3% for males, and 2% for females; and at age 18,1 % for males, and almost nonexistent for females.

Familial pattern. Approximately 75% of all children with Functional Enuresis have a first-degree biologic relative who has, or has had, the disorder. The concordance for the disorder is greater in monozygotic than in dizygotic twins.

Differential diagnosis. Organic causes of enuresis such as diabetes, seizure disorder, and urinary tract infection should be ruled out by appropriate physical examinations.

Diagnostic Criteria for Functional Enuresis

A. Repeated voiding of urine during the day or night into bed or clothes, whether involuntary or intentional.

B. At least two such events per month for children between the ages of five and six, and at least one event per month for older children.

C. Chronologic age at least five, and mental age at least four.

D. Not due to a physical disorder, such as diabetes, urinary tract infection, or a seizure disorder.

Specify primary or secondary type.
Primary type: the disturbance was not preceded by a period of urinary continence lasting at least one year.

Secondary type: the disturbance was preceded by a period of urinary continence lasting at least one year.


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