Toilet training and psychological dyschezia: Behavioral therapy in young children
Acquisition de la propreté et dyschésie psychologique : thérapie comportementale chez le jeune enfant
Résumé
Toilet training in children is an important step toward autonomy. Enuresis and encopresis are the most frequent difficulties met in sphincter control. Difficulties in evacuating stools are less described. Dyschezia is another kind of sphincter control disorder: the incapacity or difficulty in evacuating stools naturally. The concept of psychological dyschezia – dyschezia with a psychological etiology – has recently been developed. It is defined as either the incapacity or the difficulty in evacuating stools (difficult or slow evacuation requiring prolonged efforts), or as the retention of stools without a biological or functional anomaly. The present paper is a case study of a 4-year-old little girl who presents a symptomatology allowing the diagnosis of psychological dyschezia. This little girl, with no physiological problems or other psychological symptomatology, was only able to defecate in a diaper and refused to sit on the toilet. A functional analysis was conducted: (1) anger was shown when the girl was asked to sit on the toilet; (2) the cognition was that “it's easier to do it when I’m standing”; (3) the reinforcer was the use of diapers. The intervention consisted in successive reinforcement conditions. Although the reinforcer was the diaper, the choice was made to maintain access in order to avoid constipation. At first, the focus was on shaping the behavior “bending the knees while standing on a small footstool” while maintaining access to diapers. Using a token economy, this shaping phase was successful in a few days. In the second condition, the objective was to reinforce the behavior “pushing on the toilet” while gaining access to a diaper after pushing 2 or 3 times. The reinforcers used were a token and a special candy. This condition was unsuccessful. In a third and last condition, access to the diapers was completely removed and the special candy was maintained. This condition was a complete success in one trial. The concept of psychological dyschezia was useful to propose an intervention based on cognitive and behavior therapy for this 4-year-old girl. Nevertheless, based on the fact that the child was able to defecate with no difficulties in a diaper and to sit on the toilet to urinate, our intervention was centered on the behavior “sitting on the toilet to defecate” instead of the cognition. Other cases studies have to be described in order to develop guidelines for clinicians who are confronted to dyschezia with a psychological etiology.
L'acquisition de la propreté chez l'enfant est une étape importante vers l'autonomie. Si l'énurésie et l'encoprésie sont les difficultés les plus fréquemment décrites pour ce qui a trait au contrôle sphinctérien, la difficulté d'exonération des selles est peu documentée. Récemment, la dyschésie psychologique et sa prise en charge dans un abord cognitivo-comportemental ont été décrites. Le présent article vise à présenter le déroulement de la thérapie telle que nous l'avons conçue et réalisée chez une jeune enfant pour laquelle les cognitions étaient peu accessibles. L'utilisation conjointe du façonnage, en utilisant des renforçateurs secondaires, puis primaires, et la suppression de tout accès aux couches-culottes s'est avérée un succès. D'autres cas cliniques sont à décrire afin de fournir aux cliniciens des outils appropriés pour l'accompagnement de l'enfant et de sa famille.
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