31.10 Elimination Disorders
1211
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. Furthermore, par-
ents 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. This training process for parents is done in an intense
manner within a short period of time. Many parents are able to
facilitate improved eating patterns in the infant as a result. If the
mother or caregiver is unable to participate in the intervention, it
may be necessary to include additional caregivers to contribute
to feeding the infant. In rare cases, an infant may require hos-
pitalization until adequate nutrition on a daily basis is accom-
plished. If an infant tires before ingesting an adequate amount
of nutrition, it may be necessary to begin treatment with the
placement of a nasogastric tube for supplemental oral feedings.
For older children with failure-to-thrive syndromes, hos-
pitalization and nutritional supplementation may be necessary.
Medication is not a standard component of treatment for feeding
disorders; however, there are anecdotal reports of preadolescents
with failure-to-thrive and feeding disorders who were comor-
bid for anxiety and mood symptoms and who received enteral
nutritional interventions in addition to risperidone (Risperdal),
and who were observed to have an increase in oral intake and
accelerated weight gain.
R
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▲▲
31.10 Elimination
Disorders
The developmental milestones of mastering control over bowel
and bladder function are complex processes that involve motor
and sensory functions, coordinated through frontal lobe activi-
ties, and regulated by neurons in the pons and midbrain area.
Mastery of bowel and bladder function is achieved over a period
of months for the typical toddler. Infants generally void small
volumes of urine approximately every hour, commonly stim-
ulated by feeding, and may have incomplete emptying of the
bladder. As the infant matures to be a toddler, bladder capacity
increases, and between 1 and 3 years of age, cortical inhibitory
pathways develop that allow the child to have voluntary con-
trol over reflexes that control the bladder muscles. The ability to
have muscular control over the bowel occurs even before blad-
der control for most toddlers, and the assessment of fecal soiling
includes determining whether the clinical presentation occurs
with or without chronic constipation and overflow soiling. The
normal sequence of developing control over bowel and blad-
der functions is the development of nocturnal fecal continence,
diurnal fecal continence, diurnal bladder control, and nocturnal
bladder control. Bowel and bladder control develops gradually
over time. Toilet training is affected by many factors, such as a
child’s intellectual capacity and social maturity, cultural deter-
minants, and the psychological interactions between child and
parents. The ability to control bowel and bladder functions
depends on the maturation of neurobiological systems, so that
children with developmental delays may also display delayed
continence of bowel and bladder. When children exhibit incon-
tinence of urine or feces on a regular basis, it is troubling to
the child and families, and often misunderstood as voluntary
misbehavior.
Encopresis (repeated passage of feces into inappropriate
places) and enuresis (repeated urination into bed or clothes) are
the two elimination disorders described in the Fifth Edition of
the American Psychiatric Association’s
Diagnostic and Statis-
tical Manual of Mental Disorders
(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 develop-
ing child is expected to master these skills. Normal develop-
ment encompasses a range of time in which a given child is
able to devote the attention, motivation, and physiological skills
