Acquisition de la propreté et dyschésie psychologique: thérapie comportementale chez le jeune enfant

Abstract

Toilet training in children is an important step toward autonomy. Enuresis and encopresis are the most frequent difficulties met in sphincter control. Difficulties in evacuating stools are less described. Dyschezia is another kind of sphincter control disorder: the incapacity or difficulty in evacuating stools naturally. The concept of psychological dyschezia - dyschezia with a psychological etiology - has recently been developed. It is defined as either the incapacity or the difficulty in evacuating stools (difficult or slow evacuation requiring prolonged efforts), or as the retention of stools without a biological or functional anomaly. The present paper is a case study of a 4-year-old little girl who presents a symptomatology allowing the diagnosis of psychological dyschezia. This little girl, with no physiological problems or other psychological symptomatology, was only able to defecate ina diaper and refused to sit on the toilet. A functional analysis was conducted: (1) anger wasshown when the girl was asked to sit on the toilet; (2) the cognition was that "it's easier todo it when I'm standing"; (3) the reinforcer was the use of diapers. The intervention consistedin successive reinforcement conditions. Although the reinforcer was the diaper, the choice wasmade to maintain access in order to avoid constipation. At first, the focus was on shaping thebehavior "bending the knees while standing on a small footstool" while maintaining accessto diapers. Using a token economy, this shaping phase was successful in a few days. In thesecond condition, the objective was to reinforce the behavior "pushing on the toilet" whilegaining access to a diaper after pushing 2 or 3 times. The reinforcers used were a token anda special candy. This condition was unsuccessful. In a third and last condition, access to thediapers was completely removed and the special candy was maintained. This condition was acomplete success in one trial. The concept of psychological dyschezia was useful to proposean intervention based on cognitive and behavior therapy for this 4-year-old girl. Nevertheless,based on the fact that the child was able to defecate with no difficulties in a diaper and to siton the toilet to urinate, our intervention was centered on the behavior "sitting on the toiletto defecate" instead of the cognition. Other cases studies have to be described in order todevelop guidelines for clinicians who are confronted to dyschezia with a psychological etiology.