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  2. 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. 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. 4. SEQUENCE OF NORMAL DEVELOPMENT Nocturnal bladder control Diurnal bladder control Diurnal fecal continence Nocturnal fecal continence
  5. 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. 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. 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. 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. 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. 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. 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. 12. • Psychotherapy: concomitant behavioral problems • Pharmacological: Imipramine( 25-75 mg) Cisapride
  13. 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. 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. 15. CLASSIFICATION • Nocturnal (night-time) • Diurnal (daytime) • Nocturnal and diurnal Primary Secondary
  16. 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. 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. 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. 19. MEDICAL CAUSES • UTI • Urethritis • Diabetes • Seizure disorder • Neurogenic bladder
  20. 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. 21. Low self esteem Teasing by peers Social rejection Avoidance of social gatherings Anxiety Anger outbursts
  22. 22. EVALUATION • Medical evaluation – Urine analysis – Physical exam • Family history • Psychosocial factors
  23. 23. TREATMENT • Primarily behavioural and pharmacological. • Psychotherapy may be useful for ameliorating some of the associated behavioral problems
  24. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 46. • Metoclopramide • Cimetidine • Antipsychotics such as haloperidol and thioridazine have been cited to be helpful
  47. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 57. THANK YOU