1.
ELIMINATION
DISORDER
AND
FEEDING/EATING
DISORDER OF
CHILDHOOD
AKANKSHA SHANKAR
JUNIOR RESIDENT
MODERATOR: PROF. VIVEK
AGARWAL, M.D.

2.
ELIMINATION DISORDER
• Encopresis (repeated passage of feces into inappropriate
places) and Enuresis (repeated urination into bed or clothes)
are the two elimination disorders described in DSM-5.
• These diagnoses are not made until after age 4 years, for
encopresis, and after age 5 years for enuresis, the ages at
which a typically developing child is expected to master these
skills.

3.
INFANT
Voids small amount
of urine every hour
TODDLER
(1-3 years)
Cortical inhibitory
pathways develop
Bowel continence
Bladder continence
PRE-SCHOOL
Voluntary control
over bladder &
bowel movements

4.
SEQUENCE OF NORMAL DEVELOPMENT
Nocturnal bladder control
Diurnal bladder control
Diurnal fecal continence
Nocturnal fecal continence

5.
ENCOPRESIS
• Repeated passage of feces into
inappropriate places (e.g., clothing, floor),
whether involuntary or intentional. (The
disorder may involve overflow incontinence
secondary to functional fecal retention)
occurring once per month for at least 3
months (DSM-5) or 6 months (ICD-10).

6.
EPIDEMIOLOGY
• Globally, community prevalence of encopresis
ranges from 0.8 to 7 .8 percent.
• Males are three to six times more likely to
have encopresis than females.
3 % (3 years of age)
1.6 % (10 years of age)
0.75 % (10-12 years od age)

7.
CLASSIFICATION
1. Intentional—children who do have bowel
control but intentionally deposit feces in
inappropriate places for psychological reasons
2. Involuntary—those who cannot adequately
control the sphincter or lack an awareness of the
process, or both
3. Involuntary —those whose soiling is related to
excessive fluid from retentive overflow (75
percent of this category), diarrhea, or anxiety
Primary
Secondary

8.
ETIOLOGY
• 90 percent of chronic childhood
encopresis is considered to be
functional
• Chronic constipation
• Inadequate toilet training
• Fear of school bathroom, or toilet related
fears
• Mechanisms include altered colon
motility, and contraction factors,
obstruction, stretched and thinned colon
walls, and decreased sensation
secondary to neurological disorder.
• May be deliberate attempt, as a means
of avoiding stressors or communicating
anger
Predominantly psychological.
(1)a distant father and neurotic
mother
(2) early and often harsh bowel
training
(3) a history of neurological delay
Chronic Neurotic Encopresis

9.
DIFFERENTIAL DIAGNOSIS
• Encopresis can be a symptom of other processes or can be a
syndrome in itself.
• Stenosis of the rectum or anus, endocrine abnormalities,
smooth muscle disease, and Hirschsprung’s disease.
• Intellectual deficits or pervasive developmental delay
• Impulse control disorders or attention-deficit disorder

10.
COURSE AND PROGNOSIS
• Behavioral interventions involving educational, behavioral, and
physiological components are striking (78 percent), suggesting
that the disorder responds to treatment in most cases.

11.
TREATMENT
• The first clinical approach to encopresis is primarily behavioral,
with educational and physiological components
BEHAVIORAL EDUCATIONAL PHYSIOLOGICAL
Daily timed intervals
on the toilet, with
success being
rewarded
Correct misconceptions
Dissipate anxiety that
may develop around the
soiling
Abnormal defecation
dynamics in children with
encopresis led to interest
in biofeedback training as
an adjunctive treatment

12.
• Psychotherapy: concomitant behavioral problems
• Pharmacological: Imipramine( 25-75 mg)
Cisapride

13.
ENURESIS
• Repeated voiding of urine into bed or
clothes (whether involuntary or
intentional) occurring twice a week for
at least 3 consecutive months.
• Significant distress or impairment in
social, academic (occupational), or
other important areas of functioning.

14.
EPIDEMIOLOGY
• More common in boys.
• Frequent co morbidities: ODD, ADHD
• Behavior problems, Developmental delays
• Learning disabilities, Poor school achievements
• Secondary Enuresis related to stress, trauma, or psychological
crisis
5-10% in 5 years-old
3- 5% in10 years-old
1-2% in 15 years-old

15.
CLASSIFICATION
• Nocturnal (night-time)
• Diurnal (daytime)
• Nocturnal and diurnal
Primary
Secondary

16.
ETIOLOGY
• Voluntary intentional wetting- Oppositional defiant disorder
(ODD) or a psychotic disorder
• Socially disadvantaged situations and experiencing
psychosocial stress
• Attention-deficit/hyperactivity disorder (ADHD).

17.
ENURESIS: GENETICS
• In one study, researchers evaluated 11 families with primary
nocturnal enuresis (PNE) over three generations in a pattern
that was suggestive of an autosomal-dominant inheritance, with
penetrance greater than 90 percent.
• While this gene located on chromosome 13q, no specific locus
on this chromosome has yet been identified.
• Some studies also implicated chromosomes 4p, 8,12q, 22 and
AQP2 locus.

18.
ROLE OF ANP & AVP
• Circadian variation of plasma Atrial natriuretic peptide (ANP)-
some children lack the ability to concentrate urine produced
during the night and thus cannot reduce urine volume, and
manifest enuretic episodes as a result
• Endogenous arginine vasopressin(AVP) are also found to be
associated but no consistent correlation has been found.

19.
MEDICAL CAUSES
• UTI
• Urethritis
• Diabetes
• Seizure disorder
• Neurogenic bladder

20.
COURSE AND PROGNOSIS
• Primary: self limited and has high spontaneous remission
• Secondary: Usually begins b/w ages 5-8 years and then drops
off substantially
• By 14 years of age, only 1.1 percent of boys wet once a week
or more
• Adolescent onset signify more psychiatric problems and less
favorable outcome.

21.
Low self
esteem
Teasing
by peers
Social
rejection
Avoidance
of social
gatherings
Anxiety
Anger
outbursts

22.
EVALUATION
• Medical evaluation – Urine analysis – Physical exam
• Family history
• Psychosocial factors

23.
TREATMENT
• Primarily behavioural and pharmacological.
• Psychotherapy may be useful for ameliorating some of the
associated behavioral problems

24.
BEHAVIORAL TREATMENT BELL & PAD
METHOD
• The bell and pad method of conditioning is a
reasonable first approach. Success rate of 75%
• Urine-sensitive pad connected to alarm
• Based on classical conditioning paradigm – Child
learns to associate alarm with feeling of full bladder
• Use of parental reinforcement
• Continuing to use the alarm intermittently

25.
• OTHER PROCEDURES :
• Include reward systems, such as star charts
• Night-time awakening to urinate
• Fluid restriction few hours at night before going to bed
• Restriction of any tea/caffeine intake in evening in adolescents

26.
PHARMACOLOGIC METHODS
• IMIPRAMINE
• It is efficacious and approved for use in treating childhood enuresis,
primarily on a short-term basis.
• Imipramine may well be the first pharmacological choice for those
families who do not have any form of insurance and who have
limited financial resources.
• Positive response in the range from 75 to 125 mg.
• The standard maximal limit for dose is 5 mg/kg body weight, and
ECG monitoring is recommended at doses greater than 3.5 mg/kg
• Once the drug is discontinued, relapse and enuresis at former
frequencies usually occur within a few months.

27.
• DESMOPRESSIN
• Synthetic replacement for Arginine vasopressin ,the hormone that
reduces urine production during sleep
• Review Studies: 10%-91% success rate
• Positive prognostic factors were age (older than 9 years of age)
• Wetting resumes once medication is discontinued
• Most serious side effect (rare) is hyponatremia, leading to seizures
• Most common side effects: Nasal stuffiness, headache, epistaxis,
seizures and abdominal pain

28.
• REBOXETINE
• Nor-epinephrine reuptake inhibitor with a non-cardiotoxic side effect
profile has recently been investigated as a safer alternative to
imipramine in the treatment of childhood enuresis.
• A trial in which 22 children with socially handicapping enuresis who
had not responded to an enuresis alarm, desmopressin, or
anticholinergics were administered 4 to 8 mg of reboxetine at
bedtime. Of the 22 children, 13 (59 percent) in this open trial
achieved complete dryness with reboxetine alone, or in combination
with desmopressin.
• Side effects were minimal

29.
FEEDING AND EATING DISORDER
• Diagnostic and Statistical Manual of Mental Disorders (DSM- 5)
includes three distinct disorders of feeding and eating:
• 1) Pica
• 2) Rumination disorder
• 3) Feeding disorder of infancy or early childhood

30.
PICA
• Pica is described as persistent eating of nonnutritive
substances for at least 1 month.
• The behavior must be developmentally inappropriate, not
culturally sanctioned, and sufficiently severe to merit clinical
attention.
• More frequently in young children than in adults.
• Among adults, certain forms of pica, including geophagia (clay
eating) and amylophagia (starch eating), have been reported in
pregnant women.

31.
EPIDEMIOLOGY
• Pica is more common among children and adolescents with
mental retardation.
• A survey of a large clinic population reported that 75 percent of
12-month-old infants and 15 percent of 2- to 3-year-old toddlers
placed nonnutritive substances in their mouth.
• Pica appears to affect both sexes equally

32.
ETIOLOGY
• Lasts for several months and then remits.
• A higher than expected incidence of pica seems to occur in the
relatives of persons with the symptoms.
• Nutritional deficiencies have been postulated as causes of pica
e.g. Iron deficiency anemia
• A high incidence of parental neglect and deprivation has been
associated with cases of pica.

33.
DIAGNOSIS AND CLINICAL FEATURES
• Eating nonedible substances repeatedly after 18 months of age
is usually considered abnormal.
• Onset of pica is usually between ages 12 and 24 months

34.
DIAGNOSIS AND CLINICAL FEATURES
• The most serious complications are :
• lead poisoning (usually from lead-based paint)
• intestinal parasites after ingestion of soil or feces
• anemia and zinc deficiency after ingestion of clay
• severe iron deficiency after ingestion of large quantities of
starch
• intestinal obstruction from the ingestion of hair balls, stones, or
gravel.

35.
PATHOLOGY AND LABORATORY
EXAMINATION
• No single laboratory test confirms or rules out a diagnosis of
pica.
• Levels of iron and zinc in serum should always be determined;
in many cases of pica, these levels are low and may contribute
to the development of pica.
• A patient's hemoglobin level should be determined; if the level is
low, anemia can result.
• In children with pica, the lead level in serum should be
determined; lead poisoning can result from ingesting lead.

36.
DIFFERENTIAL DIAGNOSIS
• Differential diagnosis of pica includes iron and zinc deficiencies.
• Pica also can occur in conjunction with failure to thrive and
several other mental and medical disorders, including
schizophrenia, autistic disorder, anorexia nervosa, intellectual
disability.

37.
COURSE AND PROGNOSIS
• The prognosis for pica is usually good, because in children of
normal intelligence it generally remits spontaneously within
several months.
• In childhood, pica usually resolves with increasing age
• In adults who are mentally retarded, it lasts for years.

38.
TREATMENT
• The first step in the treatment of pica is determining the cause
whenever possible.
• Exposure to toxic substances, such as lead, must also be
eliminated.
• No definitive treatment exists for pica.
• Treatments emphasize psychosocial, environmental,
behavioral, and family guidance approaches.

39.
RUMINATION
• Rumination has been defined as repetitive
regurgitation of gastric contents that are
subsequently rechewed and then re-
swallowed or spit out.
• The regurgitation occurs very soon after a
meal and tends to persist for 1 to 2 hours.
• Rumination has been described in infants,
in individuals with development disabilities,
and in children, adolescents, and adults
with psychiatric or neurological disorders.
Increase in intra-abdominal
pressure
Initiates the reflux
Peristaltic fore contractions
Clear the intra-esophageal content.

40.
EPIDEMIOLOGY
• Rumination is a rare disorder.
• More common among male infants, and emerges between 3
months and 1 year of age.
• It persists more frequently among children and adults who are
mentally retarded.

41.
ETIOLOGY
• Rumination and gastroesophageal reflux often coexist
• In those who are mentally retarded, the disorder may be
attributed to self-stimulatory behavior.
• Psychodynamic theories hypothesize various disturbances in
the mother-child relationship as a contributing factor in the
development of rumination disorder
• Overstimulation and tension have also been suggested as
causes of rumination

42.
DIAGNOSIS AND CLINICAL FEATURES
• The essential feature of the disorder is repeated regurgitation and
rechewing of food for a period of at least 1 month after a period of
normal functioning.
• Partially digested food is brought up into the mouth without nausea,
retching, disgust, or associated gastrointestinal disorder
• Usually, the infant is irritable and hungry between episodes of
rumination
• Although spontaneous remissions are common, severe secondary
complications can develop, such as progressive malnutrition,
dehydration, and lowered resistance to disease

43.
PATHOLOGY AND LABORATORY
EXAMINATION
• No specific laboratory examination is pathognomonic of
rumination disorder.
• Rumination disorder can be associated with failure to thrive and
varying degrees of starvation.
• Thus, laboratory measures of endocrinological function (thyroid
function tests, dexamethasone suppression test), serum
electrolytes, and a hematological workup help determine the
severity of the effects of rumination disorder

44.
DIFFERENTIAL DIAGNOSIS
• Pyloric stenosis is usually associated with projectile vomiting
and is generally evident before 3 months of age, when
rumination has its onset.
• Rumination has been associated with various mental
retardation syndromes in which other stereotypic behaviors and
eating disturbances, such as pica, are present.
• Rumination disorder can occur in patients with other eating
disorders, such as bulimia nervosa.

45.
TREATMENT
• Sometimes, an evaluation of the mother-child relationship reveals
deficits that can be influenced by offering guidance to the mother.
• Behavioral interventions, such as squirting lemon juice into the
infant's mouth whenever rumination occurs, can be effective in
diminishing the behavior.
• Treatments include improvement of the child's psychosocial
environment, increased tender loving care from the mother or
caretakers, and psychotherapy for the mother or both parents
• If an infant is malnourished and continues to lose most nutrition
through rumination, a jejunal tube may need to be inserted

46.
• Metoclopramide
• Cimetidine
• Antipsychotics such as haloperidol and thioridazine have been
cited to be helpful

47.
AVOIDANT/RESTRICTIVE FOOD INTAKE
DISORDER
• Avoidant/restrictive food intake disorder, formerly known as
feeding disorder of infancy or early childhood, is characterized
by a lack of interest in food, or its avoidance based on the
sensory features of the food or the perceived consequences of
eating

48.
• Significant weight loss (or failure to achieve expected weight
gain or faltering growth in children)
• Significant nutritional deficiency.
• Dependence on enteral feeding or oral nutritional
supplements.
• Marked interference with psychosocial functioning.

49.
• Six feeding disorder subtypes are as follows:
(1) feeding disorder of state regulation
(2) feeding disorder of caregiver–infant reciprocity
(3) infantile anorexia
(4) sensory food aversions
(5) feeding disorder associated with a concurrent medical
condition
(6) feeding disorder associated with insults to the gastrointestinal
tract

50.
EPIDEMIOLOGY
• 15 percent and 35 percent of infants and young children have
transient feeding difficulties.
• A survey of feeding problems in nursery school children
revealed a prevalence of 4.8 percent with equal gender
distribution
• Data from community samples estimate a prevalence of failure
to thrive syndromes in approximately 3 percent of infants, with
approximately half of those infants exhibiting feeding disorders.

51.
DIAGNOSIS AND CLINICAL FEATURES
• It may take the form of outright food refusal, food selectivity,
eating too little, food avoidance, and delayed self-feeding
• Infants and children with the disorder may be withdrawn,
irritable, apathetic, or anxious

52.
DIFFERENTIAL DIAGNOSIS
• Structural problems with the infants' gastrointestinal tract that
may be contributing to discomfort during the feeding problems.
• Organic causes of swallowing difficulties

53.
COURSE AND PROGNOSIS
• Most infants with feeding disorder who are identified within the
first year of life and who receive treatment do not go on to
develop malnutrition, growth delay, or failure to thrive.
• In children 2 to 3 years of age, growth and development can be
affected when the disorder lasts for several months.
• 70 percent of infants who persistently refuse food in the first
year of life continue to have some eating problems during
childhood

54.
TREATMENT
• Education of the parents regarding the temperamental traits of
the infant
• Exploration of the parents' anxieties about the infant's nutrition
• Training for the parents regarding changing their behaviors to
promote internal regulation of eating in the infant

55.
With failure-to-thrive syndromes, hospitalization and nutritional supplementation
Parents are encouraged to feed the infant on a regular basis at 3- to 4-hour intervals, and offer only
water between meals
The parents are trained to deliver praise to the infant for any self-feeding efforts, regardless of the
amount of food ingested.
Parents are guided to limit any distracting stimulation during meals and give attention and praise to
positive eating behaviors rather than intense negative attention to inappropriate behavior during
meals

56.
REFERENCES
• Kaplan & Sadock’s Comprehensive Textbook of Psychiatry,
tenth edition
• Kaplan & Sadock’s Synopsis of psychiatry, eleventh edition,
Benjamin James Sadock MD, Virginia Alcott Sadock, MD,
Pedro Ruiz MD
• Diagnostic and statistical manual of mental disorders(DSM-5)
• The ICD-10 Classification of Mental and Behavioural Disorders
• The ICD-11 Classification of Mental and Behavioural Disorders

57.
THANK YOU