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Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Monday, December 10, 2012

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.

[By the way, if you came to this post looking for more general information about toilet-training, you might want to try .]


  1. The issue of bedwetting often appears in FB groups on fostering and adoption, and there are always folks who want to see it as aimed at the parents/family. The most sensible advice I've read for parents who are frustrated by the bedwetting of children who are dry during the day involves double-sheeting the child's bed, so to speak (but including an absorbent pad in each layer as well), so that the parent can easily strip off the top layer of bedding while the child goes to the bathroom to wash up and put on clean pajamas. And using a bedwetting alarm, which have been shown to be quite effective in waking up children as soon as they start to wet the bed.

    I suppose if the child is already helping out with laundry, they can help out with their own (wet) sheets as well. But anything beyond that---no matter what it's called---is just punishment for a medical/physiological condition. What decent person does that?

    As for "playing" with feces, which also (though much less frequently) comes up on fostering and adoption FB groups: I just don't know. Could it be that, due to the dictates of attachment therapy, the child's environment has been so "simplified" that they have nothing else to do? Or, like prisoners, they feel so over-controlled, mistreated, abused, and over-surveilled that smearing their feces around is a kind of political protest?

    I tend to go blank when the discussion turns to feces. Any ideas?

    1. The feces part is difficult to make sense of, and I have to wonder whether the same term is used for a variety of behaviors. A child who has some leaking because of constipation might put fingers into pants to check on whether he or she is clean, and then wipe them on something, or might try to remove slightly soiled pants and get dirty in the process. Genuine intentional smearing in someone more than four or five years old seems to me to indicate real emotional disturbance, beyond the "RAD" level... or perhaps a response to having been locked up without toilet facilities? I have a feeling we're trying to understand this without a sufficient description of what actually happens.

  2. Oh dear, I made the mistake of Googling "feces" and "RAD" together to see if I could uncover any detailed descriptions of the feces maneuvers. (I agree with you that there's little detail in the literature, if we can call it that.) The first website that surfaced has put me off my search for the evening; I feel as if I must find an exorcist for those poor RAD children who seem to be nothing if not possessed by this anomalous configuration of symptoms:

    "'All children' do not:
    - regularly wet the bed past the age of 5 or 6
    - wet the bed in response to not getting their own way, anger at bedtime or clean sheets being put on the bed
    - scream non-stop for 9 hours and not lose their voice
    - sit at the table for 4+ hours rather than say, "May I be excused from the table please?"
    - focus incessantly on food and become unable to think if food is present
    - urinate on the laundry in their room
    - remove the heating vent in their bedrooms and urinate/defecate in them
    - wipe feces on their stuffed animals
    - pick their noses till there is enough blood to cover two sleeves on their shirts
    - wipe blood, snot, etc., on the walls, blankets, toys in their rooms
    - chew through their beds
    - chew on other objects just to leave teethmarks
    - rip out their baby teeth "secretly" in the middle of the night before they're ready, leaving themselves covered in blood
    - secretly rip out their baby teeth, chew them up and then shove them down cracks in their floor so their parents and tooth fairy never see them
    - line up their shoes backwards to everyone else
    - chew the walls
    - chew the counter tops
    - take apart containers in the bathroom and fill them with water
    - break the faucet taps
    - break the drain in the sink
    - shove whole bars of soap down the sink drain because they're angry
    - wave at strangers
    - talk sweetly to strangers in an attempt to find a new home
    - constantly shop for new parents
    - attract the attention of passers-by or drive through window workers through persistent and unending eye contact and smiles "charming"
    - routinely put their clothes on backwards
    - talk non-stop
    - ask dumb questions
    - repeat what you say to no end
    - cry for no reason
    - refuse to speak to you about what is bothering them because then you might "know" something important about them
    - cry and tantrum until they throw up


    1. Um, while I'm not a psychiatrist or pediatrician, I'm pretty sure bedwetting past five or six isn't that rare. And what's the big deal about lining up shoes backward to everyone else and putting clothes on backward?

    2. My guess: it's disobedience. And disobedience means you have attachment problems. Make them attached, then they'll be obedient and grateful too. Simple, no?

      "Crying for no reason" is one that interests me. No doubt this is followed by being given something to cry about.

  3. [cont'd]

    - bang their heads against the wall
    - attack adults by lunging for them, scratching, biting, clawing pinching
    - hurt animals repetively
    - hurt other children repetively
    - hurt other children in front of the teacher who attempted to garner an apology
    - followed by hurting the teacher, all at 5 years of age
    - tell their parents they will kill them, at 3 and 4 years of age
    - tell a teacher they will kill him/her, at 4 years of age
    - scrape the paint off the walls in their room
    - need an alarm on their bedroom door so the rest of the family can sleep at night
    - purposefully throw themselves on the playground to incur injury and subsequent sympathy and attention from non-family members such as teachers
    - pick at minor sores until they keep becoming injured and leave scars
    - pull at their ears until they are separating from their heads
    - oppose abolutely everything to do with their parents
    - focus on and talk incessantly about blood, gore, death, as young as 4 years of age
    - repair damage they've caused, then damage it again, over and over
    - break or damage the nice things they've been given
    - bite other children at the age of 5 years, for no reason
    - eat 7 courses of food and ask for more
    - sneak pens into the waistband of their pants when no one is looking to ruin the sheets and walls in a room
    - defecate in their pants as old as 15 years of age
    - try to make their parents angry on a regular basis, "just to see what happens"
    - kill animals
    - try to kill their siblings by feeding them food they are allergic to
    - tell their teachers they are not fed at home
    - kiss, hug, and climb into the laps of strangers"

    RAD is such a meta-diagnosis: it covers waving at strangers and chewing through furniture, not to mention all the blood, gore, and homicidal tendencies. Or, is it an uber-diagnosis?

    In any case, my thanks go to the Ontario RAD Families organization for this enlightening read:

    Off to find a priest ...

    1. Ok, ya'll I cant help think Munchausen by proxy syndrome when I read some of these RAD accounts...and the fact that they claim the kids do better once they are out of the homes of the adoptive parents where they are having so much trouble and moved into a new family home or an RTC is seen as proof of illness...rather than parental abuse which precipitated the behavior or parental honestly doesn’t make sense...I grew up in group homes and RTCs I have seen a few very sick kids...none of whom could magically be better in a new place....not even for a honeymoon period....just long enough to fool Psychiatric hospital staff into releasing them and the some would have you believe.

    2. It all seems to connect with the basic belief that whatever the children do, they do intentionally, and therefore they are able to choose not to do it --- an attitude reflected in the current cry of praise from teacher and waiters alike, "Good choice!" (which has replaced the ubiquitous "Good j-a-a-h-b").

  4. So, basically the idea seems to be that the children are bad, and therefore the adoptive parents must be good. This reminds me of Nancy Thomas's statement that you can tell which adoptive parents are the good ones, because their children still have their arms and legs and heads attached.

    Should this view of RAD be assessed as a specialized form of childism rather than a diagnosis?

  5. Yes: childism. Plain and simple.

  6. On reading RAD forums/blogs I am often struck by the sheer level of hate towards children, masquerading as care. Undoubtedly there are some very disturbed children out there, but that many? Under the radar? Where are all these children who kill? I looked for mainstream literature on the issue and really there wasn't anything that resembled the kind of thing these people say goes on on a regular basis.

    1. Further questions: if the children are so severely disturbed, why has an agency allowed them to be in the care of amateurs, and why have the families not sought serious treatment? Have the stories of killer-children emerged from popular movies, as the belief in exorcism was apparently fostered by that movie?

      Nancy Thomas has claimed that all the children she has fostered "have killed". But, killed what? I have just put out some mouse poison-- does that mean I am a killer by this definition? Is it possible that we're talking about "lusting in our hearts" after killing?

      I would say that most children of school age have enough trouble writing neatly and buttering their bread without making a mess. Surely killing a human being past the age of infancy takes more strength and skill than kids usually have-- not to claim that such a killing has never happened, simply that both logic and evidence show that the RADniks' claims are exaggerated.

  7. On this day of the senseless loss of life due to gun violence in Newtown, CT, it's interesting to me that, in all the stories of actual serial killers and mass shooters in the US that almost never has there been any discussion by any serious investigators, reporters, or psychologists of attachment disorders. We tend to hear, instead, about either ongoing (and to use an old-fashioned word, "flagrant") mental health issues, such as paranoid schizophrenia or abuse/bullying by others that has driven the shooter to homicidal rage or, in the case of mothers who kill large numbers of their children, narcissism or post-partum depression that has developed into a form of psychosis. Am I missing anything? I'm not a student of mass killers, so I'm just casually recalling information. But, outside of the non-attachment community, I can't recall discussion of attachment disorder in any major murderous sprees. Of course, parents who bully/abuse their children as if they were the second coming of Satan might be enough to push someone over the edge ...

    1. Your point is well taken. Bowlby's view of criminal behavior associated with a poor attachment history focused on theft, not murder-- even though after World War II there were quite a few guns in England, not only for sports but sidearms that people had walked away with when they left the armed forces.

      The Newtown man, Lanza, killed his mother (and apparently with a gun she had bought),as well as attacking the school where she was a teacher, so this would seem to be something of a test case for discussion of attachment disorders. However, once again, RAD is not in fact associated with aggressive behavior, so it's quite unlikely that any conventional mental health professionals will refer to it, or that serious investigators will single out the RAD issue.

  8. If you haven't seen it already, the book by Carmeta Albarus on Lee Boyd Malvo might interest you; apparently, the author decides that attachment disorder played a part in his murderous spree, though Malvo was bonded strongly to his father early in life. Sigh ... Early bonding seems to be no hindrance to folks diagnosing RAD.

    1. I only read a review-- thanks for the reminder, I must get this.

    2. Anyway, surely it's only attachment to mothers that counts, in that world-view--

  9. Just an FYI: someone is plagiarizing posts from adoption-related blogs, including yours (this post included) and stringing them together on another blog:

    I haven't yet figured out a way to ask this person to stop plagiarizing; there is no contact information and no way to leave comments.

    1. Thanks for the heads-up-- but I'm afraid this is the Internet for you. Once material goes up here, it's free-for-all. I suppose that if I ever had to prove authorship I could point to the original date.

      Maybe this happens more often than I think-- I've sometimes wondered why a site has such mutually-contradictory posts, but I guess that's explained if someone just takes anything with some of the right words in it.