Toilet Training Concerns and Older Adoptive Children

 When I read blogs and Internet chat by adoptive parents who believe their children have some form of attachment disorder, I often see the expression of concern—and disgust—over toileting problems (for instance, see attachment.china.parenting.html). It is assumed that children over some certain age are capable of controlling bladder and bowels, that lapses are usually intentional attacks against adult caregivers, and that the child’s efforts to “hide the evidence” only show what liars and sneaks they are.

This set of beliefs is fostered by the continued circulation of a 1996 paper by Keith Reber (referred to on many adoption and attachment therapy sites, but I can’t find a URL for it at the moment). Reber, who incidentally later had his professional license revoked , stated in that paper that various physical acts like vomiting and defecation were intentional actions of children with Reactive Attachment Disorder and were expressions of rage about abandonment by the birth mother.   Regarding physical processes as intentional, of course, leads to the assumption that if the child wanted not to vomit, or urinate, or defecate, he or she would be able to inhibit these impulses. What follows as the day the night is often a plan to give the child good reason to control bodily functions by providing punishments, or, to use the language associated with attachment therapy, consequences.

Given that even healthy adults may urinate or defecate involuntarily, or be unable to do either at will, why would it be assumed that older children are always in control of elimination? There are various “psychological” (i.e., non-physical, non-biological) explanations that can be deployed to support this assumption--  although, as I’ll point out, there are reasons to doubt the applicability of each of them.

The first “psychological” explanation comes from common observations and interpretations of the behavior of pet animals. When their environments are disrupted and they are made anxious, cats and dogs sometimes urinate and defecate at unusual times and places. Pet owners and even some veterinarians interpret this behavior as an expression of anger or resentment toward the owner--  even though the animal’s general behavior displays anxiety rather than any anger cues like growling, hissing, or direct attack. The animal’s actions may be an attempt to find a place for elimination that resembles the usual setting, so for instance a cat inadvertently shut in a bedroom may defecate on a pillow rather than in the preferred but unavailable litter box. At other times, the behavior may be a form of displacement--  performing a normal behavior in an unusual situation, as when birds preen or humans yawn in response to anxiety. In none of these cases is the eliminative lapse due to anger, although they are commonly interpreted in that way. Thus, these animal situations are not a good foundation for assuming that children’s toileting problems are due to their anger.

A second problematic “psychological” explanation, the psychoanalytic concept of repression, may also lead parents to assume that children’s toileting problems are in a sense intentional. Repression is a speculative mechanism which is said to place unpleasant memories outside the reach of consciousness, and which allows those memories to motivate behaviors that may be quite undesirable. Such behaviors cannot be brought under control until the repressed memories are made conscious, but this is an uncomfortable process which the child resists. The belief in repression lacks empirical evidence but has become completely accepted in popular psychology, so “everybody knows” that this is how the human mind works. Parents are easily convinced that behavior that is a problem, and that they do not seem to be able to change, must be a direct result of children’s past traumas and a way for them to “act out” emotional concerns. This remains a common way of thinking about problems of elimination, and especially about relating such problems to sexual abuse, even though there is good evidence that people do not usually repress even very horrible memories (although they may suppress or try not to think about them). The lack of evidence for repression argues against the use of this concept to explain why some children have unusual toileting problems.

A third “psychological” explanation is one that frequently occurs in discussions of “attachment therapy” for adopted children. Proponents of this way of thinking hold that children who have been deprived of emotionally warm, nurturing care become frightened of emotional closeness and attempt to withdrawn when they feel themselves moving toward attachment relationships. Their fear, it is said, leads them to “sabotage” such relationships by behaving hatefully or disgustingly toward adult caregivers—and inappropriate urination and defecation are certainly effective ways to do this. Caregivers may complain that a child soils underwear or fails to wipe properly, or wets underpants and then hides them, and so on--  even though the child is apparently quite old enough for bowel and bladder control. The explanation given for these actions is that the child is afraid of getting close to someone and being disappointed, as an adult might be after experiencing several failed marriages.

How do we argue for or against this explanation? Children’s histories can be so complicated that it is very difficult to figure out why a behavior occurs. But is it plausible to claim that a child shows the behaviors just described, or similar ones, because they are trying to avoid the fearsome experience of emotional intimacy? Maybe examining an analogy will help out here. What happens when young children are deprived of food or underfed for a period of time? Would we expect such children to be frightened of food or to avoid situations where there are plenty of appetizing goodies? This seems most unlikely, and it is much more probable that such children will be preoccupied with food, hoard it, even steal it. Why then assume that lack of emotional warmth will make children afraid of attachment? And if there is no reason to think they are afraid of attachment, how can we attribute their behavior to such fear? The “attachment therapy” explanation of toileting problems thus seems as unacceptable as the other “psychological” approaches.

So, what do we have left? The common psychological explanations seem unsupported. In addition, it’s a good idea to keep in mind the rule of parsimony--  that if several possible explanations are offered, and no reason exists to choose any particular one, it is safest to go with the simplest explanation. Without implying that psychological explanations are never correct, the principle of parsimony suggests that non-psychological, physiological explanations may be the best approach to some problems of behavior, especially those with strong biological components, like elimination.

I want to offer some possible physiological explanations for the toileting problems reported by some adoptive parents. (I’ll provide some sources for this information at the end of this post.) First, let me mention bedwetting. Unless a child is frightened to get up for some reason, bedwetting occurs during sleep, is not under conscious control, and is not very responsive to daytime training methods. About 75% of boys, and quite a few girls, are not reliably dry at night until age 5, and some individuals go on for years wetting at night in spite of their own and everyone else’s best efforts. The developmental  step of staying dry at night is largely under genetic control, whereas the steps in successful daytime control are much more responsive to the child’s experiences. However distressing and annoying it may be to have a large child wet the bed, the problem is not likely to be solved by punishments, rewards, or psychotherapy either conventional or unconventional.

Daytime bowel and bladder control is responsive to training. However, in the cases of adopted or foster children, the child and the caregiver may have to deal with the results of training efforts and experiences that occurred long before the present placement. For example, the child may have had to hold urine so long that the bladder muscles have become insensitive to the pressure of a full bladder. The child does not urinate often, and as a result may develop urinary tract infections or experience leaks that do not empty the bladder completely (hence, perhaps, those moist panties that are hidden somewhere until the smell reveals them). Having to wait to move the bowels--  or fear of a painful bowel movement--  can create a similar situation in the colon. In that case, softer stools may leak around the hard stool retained in the colon, staining underwear and creating confusing sensations which the child cannot trust as an indication that it’s time to go to the toilet.

If the adopted child has already developed these problems, it may be necessary to see a urologist and/or a gastroenterologist in order to understand and work with the physiological causes of the difficulty. This should be presented as help, not as punishment, because the child is in fact not intentionally behaving inappropriately. Drinking a lot of water (not carbonated beverages, fruit juices, or caffeinated drinks) and using a timer as a reminder of the time to urinate can help retrain a bladder that has become insensitive. Water is also helpful for constipation, and so are food with plenty of fiber and a lot of exercise (children with physical disabilities may need professional help in the area of exercise).

What if a child develops bowel and bladder problems after adoption? I would suggest thinking over carefully whether certain precepts of popular attachment therapy are being followed. For example, is the parent convinced that the child must go through a period of complete dependency in order to mature emotionally? Those who are advocates of this belief may require that the child ask for everything that is needed, whether a drink of water or the use of the toilet, and do nothing without permission from the adoptive parent. This is oftenenforced by placing an alarm on the child’s bedroom door or locking the door. Children may be severely punished by “paradoxical interventions” such as forced drinking if they have taken a drink without asking (one child died of hyponatremia as a result of this tactic). Children may also have “consequences” like limitation of food to peanut butter sandwiches. Limited water intake, limited and low-fiber food, and constraints on toilet use--  can you tell me a better way to cause eliminative dysfunctions? Where these practices are in use, I submit that there is no need to seek a “psychological” explanation of toileting difficulties.

Some sources:

Presentation by Dr.Christine Kodman-Jones for Delaware Valley Group of the World Association for Infant Mental Health, Dec. 7, 2012.

http://www.chop.edu/healthinfo/toilet-training.html

http://www.medicine.virginia.edu/clinical/departments/urology/patients/peds-urology/parents/home-page

[By the way, if you came to this post looking for more general information about toilet-training, you might want to try http://dvgwaimh.blogspot.com/2012/12/a-relational-approach-to-toilet.html .]
.