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.
[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 .]
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