6.1 Psychological Issues and Cognitive Behavioural Aspects
Behavioural problems and manifest psychological disorders are more common in children with incontinence than in those without. Research suggests that children with incontinence often have lower self-esteem and may have subclinical symptoms such as sadness and anxiety. In urotherapy, understanding these behavioural disturbances is crucial to recognize them and tailor the training program accordingly to achieve optimal results and reduce incapacitation. It is recommended to screen all children with behavioural questionnaires. When deciding on treatment, it is important to assess whether psychological problems are subclinical, in which case urotherapy and counselling of parents and children alone is sufficient. If a clinically relevant disorder is suspected, then for a referral to a child psychologist or psychiatrist for further assessment should occur. Manifest disorders include neurodevelopmental disorders (such as ADHD, Autism Spectrum Disorders) and others (such as depressive, anxiety and conduct disorders).
To achieve treatment goals, urotherapy uses non-pharmacological and non-surgical methods, focusing primarily on behavioural interventions rooted in cognitive behavioural therapy (CBT). CBT is a therapeutic approach that actively engages the child and parents, with cognitive therapy focusing on dysfunctional thoughts and cognitions – and behavioural therapy emphasising structured, action-oriented techniques. As a urotherapist, you will incorporate elements of behavioural therapy into your practice to effectively address incontinence issues.
Learning objectives:
The participant
- Can explain the additional role of psychology in children with incontinence
- Is familiar with the most common neurodevelopmental and other disorders in children with incontinence
- Is familiar with behavioural questionnaires that help in considering a referral to a psychologist or psychiatrist
- Can explain the basic principles of cognitive-behavioural psychotherapy (CBT)
- Is familiar with specific CBT elements such as registration, shaping, reinforcement, exposure and inhibition within the context of urotherapy.
Literature
Book: Pediatric incontinence - evaluation and clinical management: evaluation of bowel and bladder dysfunction Section: Chapter 6 Psychological aspects in bladder and bowel dysfunction, A v Gontard
Niemczyk J, Equit M, Hoffmann L, von Gontard A. Incontinence in children with treated attention-deficit/hyperactivity disorder. J Pediatr Urol. 2015 Jun;11(3):141.e1-6. doi: 10.1016/j.jpurol.2015.02.009. Epub 2015 Mar 12. PMID: 25863677.
von Gontard A, Equit M. Comorbidity of ADHD and incontinence in children. Eur Child Adolesc Psychiatry. 2015 Feb;24(2):127-40. doi: 10.1007/s00787-014-0577-0. Epub 2014 Jul 1. PMID: 24980793.
Joinson C, Heron J, von Gontard A. Psychological problems in children with daytime wetting. Pediatrics. 2006 Nov;118(5):1985-93. doi: 10.1542/peds.2006-0894. PMID: 17079570.
Niemczyk J, Fischer R, Wagner C, Burau A, Link T, von Gontard A. Detailed Assessment of Incontinence, Psychological Problems and Parental Stress in Children with Autism Spectrum Disorder. J Autism Dev Disord. 2019 May;49(5):1966-1975. doi: 10.1007/s10803-019-03885-6. PMID: 30637526.
Chase J, Bower W, Gibb S, Schaeffer A, von Gontard A. Diagnostic scores, questionnaires, quality of life, and outcome measures in pediatric continence: A review of available tools from the International Children's Continence Society. J Pediatr Urol. 2018 Apr;14(2):98-107. doi: 10.1016/j.jpurol.2017.12.003. Epub 2018 Feb 2. PMID: 29429829
von Gontard A, Hussong J, Yang S, Chase J, Franco I, Wright A (2022). Neurodevelopmental disorders and incontinence in children and adolescents: Attention-deficit-/hyperactivity disorder (ADHD), Autism spectrum disorder (ASD) and Intellectual disability (ID) - a position document of the International Children’s Continence Society (ICCS). Neurourology and Urodynamics, 2022 Jan;41(1):102-114
von Gontard A, Baeyens D, Van Hoecke E, Warzak W, Bachmann C: Psychological and psychiatric issues in urinary and fecal incontinence. J Urol 185, 1432-1437, 2011; update 2024
6.2 What If It Is Not Successful? Addressing refractory bladder issues & Behavioral Problems
Introduction
Several factors can influence the treatment process or hinder its success. When urotherapy fails to improve symptoms, it can be difficult to determine whether medical or behavioural issues are responsible for the treatment failure. It is important to distinguish between primary and secondary problems. Correctly ruling out hidden medical aspects is essential before addressing behavioural issues.
When standard approaches are ineffective, you will investigate underlying causes and adapt therapy, especially in cases of refractory overactive bladder or behavioural problems such as ADHD or ASD.
In addition, structured training programs have been developed for children with treatment-resistant incontinence (Equit et al., 2015). These can be administered in individual and group settings and include a wide spectrum of interventions including provision of information, relaxation and stress-reduction techniques and CBT.
Case studies will help you explore how child, family and environmental factors affect training and guide adjustments to your approach.
Learning objectives
The participant
- Can explain and apply how urotherapy is adaptable based on behavioural problems in children with incontinence
- Identify potential barriers to successful treatment, whether medical or behavioural, and develop strategies to address them.
Literature
Wiener JS, Scales MT, Hampton J, King LR, Surwit R, Edwards CL. Long-term efficacy of simple behavioral therapy for daytime wetting in children. J Urol. 2000 Sep;164(3 Pt 1):786-90. doi: 10.1097/00005392-200009010-00048. PMID: 10953156.
Equit, M., Sambach, H., Niemczyk, J., von Gontard, A. (2015). Urinary and fecal incontinence – a training program for children and adolescents. Boston/Göttingen: Hogrefe Publishing
von Gontard A, Hussong J, Yang S, Chase J, Franco I, Wright A (2022). Neurodevelopmental disorders and incontinence in children and adolescents: Attention-deficit-/hyperactivity disorder (ADHD), Autism Spectrum Disorder (ASD) and Intellectual disability (ID) - a position document of the International Children’s Continence Society (ICCS). Neurourology and Urodynamics, 2022 Jan;41(1):102-114
6.3 Advanced Assessment LUTS and Surgical Interventions / online Lecutre
Introduction
As a urotherapist, you also have a signalling function in children with unsuccessful treatment of incontinence. Constipation, urinary tract infections or obstruction may be limiting factors. Sometimes additional testing is needed to understand why standard treatment is not working.
Knowledge of additional diagnostics such as urodynamics or cystoscopy and additional treatment such as neuromodulation and catheterization or surgery is a broadening of your scope.
Learning objectives
The participant
- Can explain the purpose and procedure of invasive urodynamic investigations.
- Can identify the clinical indications for performing invasive urodynamic investigations.
- Can determine when cystoscopy is indicated based on urodynamic findings.
- Is aware of the various surgical treatment options for persistent incontinence.
- Understand the indications for surgery in the management of incontinence and be able to discuss and plan these options effectively with patients and their parents.
Literature
Book: Pediatric incontinence evaluation and clinical management: evaluation of bowel and bladder dysfunction Section 3 and 4
a. Chapter 8 Urodynamics in the pediatric patient,Beth A. Drzewiecki and Stuart B. Bauer
b. Chapter 20 Botulinum toxin in the treatment of the functional bladder, Green
Bauer SB, Nijman RJ, Drzewiecki BA, Sillen U, Hoebeke P; International Children's Continence Society Standardization Subcommittee. International Children's Continence Society standardization report on urodynamic studies of the lower urinary tract in children. Neurourol Urodyn. 2015 Sep;34(7):640-7. doi: 10.1002/nau.22783. Epub 2015 May 21. PMID: 25998310.
6.4 Q&A Discussion/ Live session online
During this online session you will have the opportunity to ask questions based on the lectures you have attended.
