Wednesday, May 16, 2012

“Why are Her Pants Wet, but Her Bed Isn’t?” or The Link Between Attention Deficit, ADHD and Daytime Incontinent Episodes

by John and Diane

A fellow foster parent came to me with a question the other day about her foster daughter having problems wetting her pants at school. She never wet her pants at home, and so she was trying to determine if this was a behavioral issue (purposely doing it for attention) or what?  As this child was somewhat new to her home, she began describing some of her other behaviors to me.

She was a hyperactive child, and would get called into the office occasionally for playing too roughly (accidentally falling into another child while playing and getting called to the office for it,) and had wet her pants at school more than once. The child did not seem to be embarrassed or care that she wet her pants at school.

She didn’t have episodes at home, and this could be because the foster Mom was watchful and reminded the daughter to use the bathroom when she seemed “squirmy.” Although the child had not been diagnosed with ADD or ADHD, it seemed like the child’s impulsive behavior, and attention issues made her a perfect candidate to lose track of time… and her bladder, resulting in wet pants during playtime or times of impulsivity.

So, for example, she may be playing, then thinks to herself that she needs to go to the bathroom, on her way to the bathroom she gets distracted by a video game her brothers are playing, and begins playing that instead, 20 minutes later, she is sitting in wet pants.

Because she may have been in a neglectful environment previous to her placement, she may be used to feeling wet, as well as the smell of incontinent, hence she is not embarrassed by it, nor does it bother her in any way. Having it bother other people may be new to her, so addressing the reasons why it is socially unacceptable, and unhealthy, is an important part of changing the behavior.  The social aspects of it don’t really come into play until the child is in about third grade and upwards, when friendships and social lives begin to develop and get affected by incontinence.  Sometimes even when confronted by peer pressure and rejection, older children with this issue, if left untreated, will blame other things on their lack of relationships and acceptance.

So, in this case, an undiagnosed and untreated ADD or ADHD may be the culprit. 

I have had kids with similar, or worse issues. I, too, would find myself reminding kids to go to the bathroom when they did the “I gotta go dance,” only to see them 10 minutes later, still dancing, but doing something else with one of the other foster kids.  Second reminders usually did the trick, but at school, teachers can’t remind the kids to go to the bathroom.

 Once ADD or ADHD is diagnosed, medications can help calm them down, and give them the impulsivity control necessary to stay on track long enough to tend to their own natural biological urges. Remember though, even when on medication, you have to re-teach or re-potty train some of these kids as incontinence was an accepted behavior and is now a habit that needs to be broken.

This is a much harder issue to deal with if the child comes to you with incontinence issues as an older child (teenager.)  Of course, incontinence issues are sometimes not only due to neglectful potty training, and poor living conditions, but also sexual abuse and other triggers, but once a child is an older teen, and still voiding in their pants, and seems unconcerned or unaware of it, it is nearly impossible to stop.

Trust me, I have been there. Not only is it an unpleasant and difficult task to try to work with, but when the child cannot sense the issue through olfactory means, and is not bothered by the sensation of sitting in wet or soiled clothing, and family members have allowed this to go on for 15 or 16 years, breaking this habit, and making a child realize the social ramifications, is very, very difficult. Even making the child clean the soiled clothing themselves does not solve the problem.

So, for younger children, rule out medical issues such as infections, look at ADD or ADHD factors or diagnosis and re-potty train. If age-appropriate, be sure to educate about social factors with incontinence issues.   For older kids, the psychological issues, sociological issues must also be looked at and re training can be attempted.

Do you have tips on helping kids with behaviorally influenced incontinence? Please share.  

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  1. There's another possibility, SPD - Sensory Processing Disorder, mainly low proprioceptive input. Proprioceptive is knowledge of ones own body. Ques for thirst, hunger, pain, full bladder, bowel movement, etc are all messed up. Either not coming in at all, too slowly, or unrecognized. (Also the ques are coming in too loudly, or constantly changing.) SPD can also be seen as a kid easily led to distraction and unable to dial themselves back. My daughter has this issue among other drawbacks.

    Thanks for the website. I'm learning a lot and getting good insight for writing up our rules for the completion of our homestudy.

  2. Thanks Jenny, that is great information! I will have to look more into that. Glad that our house rules can help with your home study. Good luck to you!
    John and Diane

  3. Diane, very true regarding older children. We took in a 15 year old girl once who still had issues with wetting her pants. At that age, it's a different ballgame. Hers was situation of a lifetime of neglect, lack of potty training (when younger), ADD/ADHD, etc.

    My suggestion for those dealing with older children is to first create a home environment of stability and acceptance. Rather than make her clean up or punish her, or anything else, we first went out and got a case of Goodnites (larger pullups). We did not comment at all on her pants wetting except to let her know that we expected her to wear the Goodnites and, at first, we ended up often having to remind her to change herself. We focused on other aspects of her social development first. Only later did we then tackle the pants wetting. I basically did what I would consider age appropriate re-potty training. I took her to Victoria's Secret to pick out some nice, new underpants as her ultimate goals. I also took some regular Hanes ones and made basically training pants by sewing in extra layers. She didn't make it 100% but we did get to the point she could manage underwear with a small pad, which I viewed as a huge victory.

    1. Great! Sounds like you did have a victory! I agree with your approach and that is exactly what I would have done as well. We call that the "Jesus Mode" approach, to rebuild her self esteem and feelings of safety and security and then start working on her issues. Glad it had some success for you and your teen.
      John and Diane- FPR

    2. Thanks, John and Diane! I love that phrase "Jesus Mode"! :-)

      My big advice with anyone with an older child with incontinence issues is to first make your house not only a home, but a haven. We focused on making our house a rock-solid place where she would feel 100% accepted and loved. A big part of that was putting the wetting issues way off to the side. Each child is different, but I think for "hard" cases it's best to NOT expect the child to take ownership of the issue, or expect them to clean up. Goodnites, Pull-ups, diapers, etc. are a godsend. The key is to make it clear that it is NOT a punishment and that it's to make their life easier for what is at first another traumatic change in home and environment.


  4. We have a newly Adopted 14 year old daughter and we put her into cloth diapers and rubberpants right away for her bedwetting and daytime accidents,the only problem is she likes wearing them and acts like a baby sometimes.

    1. Don't allow her to rely on the diapers etc or she will never transition to the toilet. Depending on her history and trauma, you may have to retrain her as if she were a toddler - toilet train her, and summer is the perfect time to do this since she's not in school. If she never had a real Infancy experience, it may be that is what she is clinging too. You may have to treat her as a baby- in the sense that you make her rely on you for all things... meals, clothing for the day, everything, keep her close at all times, and make her use the toilet every 2 hours. Slowly give her more independence, as you would a child... Read up on this and bring her around to where she wants to act more independently and toilet herself.