A four-year-old boy presented with sphincter control problems.
The mother consults because the child shows voluntary retention of feces and urine and total refusal to sit on the toilet.
She says that the child asks and requires parents to punish the diaper, and only then does the bowel movements.
Origin and history of the problem
The median interview shows that sphincter control is acquired from two and a half years, since the child has not presented any episode of involuntary voiding or deposition of clothes from that time.
There was an attempt by parents to remove the diaper and start using the toilet at 22 months of age, but he was not able to learn how to speak negatively about the episode, etc. showing this failure.
Update: usual sequence of the problem and maintenance factors
Usually, the child does not wear the diaper but, when he/she detects desire to be infected or not, asks his/her mother to see the diaper at the time.
If she consents, the child performs the bowel movements and the mother cleans it later and changes it.
Occasionally there are difficulties, because the child refuses to detach from the diaper.
If the mother refuses to put on her diaper, the child urinates and stools, even for hours, and shows disturbing behavior with manifestations of intense anger, crying.
The concern of the parents for the possible discomfort of the child resulting from the retention, and the inability to tolerate and manage their behavior changes, these statements and accept to put on diaper, moment in child
At present, the problem has a daily frequency and interferes in many areas of the child's life: in the school context, it is the only child in the class who does not feel in the bathroom that leads to rejection and rejection.
Family routines are also altered by this problem, so that they have stopped performing some activities and parental discomfort is significant.
Developmental development
The mother's pregnancy resulted from in vitro fertilization (IVF); the child was very desired and both parents expressed great fear of losing it.
After birth, the mother manifests the "desire to give her a brother", but there is the impossibility of a new fertilization for medical reasons.
She reports feeling guilty for this situation and also manifests fear of collating errors in the child's education.
The patient has slight delays in the onset of gait and language development.
She presents walking with support at 19 months and the mother reports that the first sentences the child gave were at three years, two weeks after the beginning of schooling.
Before this moment, he only used three words and gestures to communicate, which led to an assessment in Early Intervention.
As for the autonomy and other behaviors, through the discourse of the mother significant elements are found in the early temperament of the child.
It is very difficult for him to tolerate changes and novelty; he may even refuse to participate in playful and pleasurable activities if they were not foreseen or not performed in the way he did.
It actively resists activities outside the routine and shows an attitude of rigidity.
It carries out a series of "early situations" that could be considered normal in any child of your age, but that exceed the usual frequency and intensity.
For example, play a toy every night in your room and show inability to sleep if not done.
You can only stay sitting watching TV if both parents sit with him on the couch, one side by hand.
The mother describes constant verification behaviors, such as as as asking her mother 20 or 30 times a day if she wants to.
He also mentions a negative attitude towards the trips or any situation that alters his routine, with great difficulties to sleep if not in his bed and continuous protests with desire to return home.
Primary Care Intervention
The mother and the child go to the pediatrician's office, who performs the first detection of the problem.
After ruling out the presence of constipation, abdominal discomfort, pain when defecating and other factors that could indicate organicity, an exploration of other factors that appear confined to the manifest symptomatology is carried out.
By detecting the presence of psychological factors (behavioral, family and personal) that may be influencing the problem, we begin collaboration with the resident of Clinical Psychology (PIR) who rotated at that time in PC.
Since then, the case was addressed jointly: the RIP carried out some individual sessions with the parents and the child for the management of the problem, and the pediatrician continued monitoring the child by incorporating the global approach and learning the case.
