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CHAPTER 37 • Mental Disorders of Childhood and Adolescence

education about the disorder, medications, and long-term management (including use of community resources) is an essential part of the treatment plan. Long-term management also requires monitoring of chronic anti psychotic therapy. ❚ ELIMINATION DISORDERS ENURESIS Enuresis is the involuntary excretion of urine after the age at which the child should have attained bladder con trol. It usually involves involuntary bedwetting at night, but repeated urination on clothing during waking hours can occur (diurnal enuresis). Enuresis is a self-limiting disorder, with most children experiencing a spontaneous remission. Epidemiology and Etiology The prevalence of nocturnal enuresis varies with age and sex assigned at birth, being most common in young male children—an estimated 20% of 5-year-old and 10% of 7-year-old children have nocturnal enuresis (AACAP, 2023). The frequency in female children is about half that of male children in each age group. The etiology of enure sis is unknown, with probably no single cause. Most chil dren with nocturnal enuresis have no urologic anomalies. Causes of bedwetting might include the inability of the child’s bladder to hold urine overnight, constipation that is placing pressure on the bladder, and deep sleep result ing in the inability of the child to wake up. Bedwetting may also be a result of stress and emotions. For example, a child may begin bedwetting following a significant life change such as moving to a new home, parental divorce, loss of a loved one, or trauma (AACAP, 2023). EVIDENCE-BASED NURSING CARE OF CHILDREN WITH ENURESIS Nursing assessment should include the child’s develop mental history, the onset and course of enuresis, prior treatment, presence of emotional issues, and medical history. Routine laboratory tests such as urinalysis and a urine culture are used to identify the presence of infec tion. The nurse should obtain baseline data regarding toileting habits, including daytime incontinence, urinary frequency, and constipation. They should refer children with persistent daytime enuresis for consultation with a urologist. The nurse should also explore the family’s home environment, family attitudes about the child’s enuresis, and the family’s medical history. Parents should be educated that children rarely wet the bed intentionally, and that children generally feel ashamed. Parents should provide encouragement to their child.

In many cases, limiting fluid intake in the evening and treating constipation (if present) is sufficient to decrease the frequency of bedwetting. One of the most effective methods is the bell and pad. In this approach, the child sleeps on a pad that has wires on it, and when the child voids, a bell sounds, waking up the child. With use, the child either wakes up to urinate or learns to sleep through the night without voiding. A more temporary solution is the use of desmopressin (DDAVP), a synthetic antidi uretic hormone that actually inhibits production of urine. After medication is withdrawn, the enuresis frequently returns (Tsuji & Kaneko, 2023). ENCOPRESIS Encopresis involves soiling clothing with feces or depos iting feces in inappropriate places. Additional diagnostic criteria include that the child is older than 4 years; that the soiling occurs at least once per month; and that the soiling is not the result of a medical disorder, such as con genital aganglionic megacolon (Hirschsprung disease). The most common form of encopresis is fecal impaction accompanied by leakage around the hardened mass of stool. Because of the loss of muscle tone in the lower bowel, the child loses the usual urge to defecate and may not feel the leakage. Surprisingly, the child may not detect the smell of the stool because the olfactory appa ratus becomes accustomed to the odor. If left untreated, this issue generally resolves independently by middle adolescence. Nonetheless, the social consequences may As with enuresis, encopresis is more common in male children, and the frequency of the condition declines with age. The current estimate of prevalence is 1% to 4% of school-aged children, with a three to six times greater prevalence in male children. Approximately 20% to 30% of children with encopresis also have enuresis (DeLeon et al., 2022). The reasons for withholding stool and starting the cycle of fecal impaction are unclear but are not usually the result of physical causes. However, as noted, when fecal impaction occurs, there is an accompanying loss of tone in the bowel and subsequent leakage. EVIDENCE-BASED NURSING CARE OF CHILDREN WITH ENCOPRESIS Assessment includes a detailed interview with the child and parent regarding the pattern of the encopresis. A calm matter-of-fact approach can help to reduce the child’s embarrassment. Physical examination is also necessary; thus, collaboration with the child’s primary care provider or consulting pediatric specialist is be substantial (DeLeon et al., 2022). Epidemiology and Etiology

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