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Child Behavior
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Child Behavior

Background:  My 7-year-old son was diagnosed with ADHD at age four.  We have been under treatment since then.  He wasn't put on Ritalin until age 6, with great results (Daytrana).  In January, we moved -- new house, new (public vice Montessori) school, new doctor etc.  He has done very well -- he seemed to be making the transition well.  He is academically advanced by more than three grade levels, a very good reader, and his favorite book is my husband's college chemistry book.  He has never been bullied.  And he maintains a small but interactive social network.

Issue:  Approximately one month ago, he began to urinate on the carpet.  He blamed the dogs, then the cats.  We talked about anger management issues.  We wrote in our behavior notebook about what to do when we're angry.  He came up with solutions like "I will tell Mom when I am angry" and "I will take a time out and think about it when I'm angry."  And we wrote down things he will not do when he is angry like "I will not pee on the carpet" and "I will not yell at others."  We took away his favorite toys (Legos) for a week and tried to focus on behavior management.

Question:  He has never exhibited physical aggression or tantrums.  We are not regular physical disciplinarians.  We try to find alternatives that include time-outs and priviledge denial as punishments.  Is this passive-aggressive urination a precursor to ODD/CD?  What other parental options can I exercise to help him?  What questions do I need to ask his doctor at our next appointment (next week) that will help me find alternative ways to manage his behavior and help him be successful?

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Hello Lisa,
    wow, peeing on the carpet, I'd bet you thought those days were long gone. Its great that you have made the first step going to the pediatrician, as there could be medical reasons for a child suddenly having bladder control problems (some kids just have a bladder that is small as compared to the rest of their body, and your pediatrician will rule-out a urinary tract infection or other problem). My first question for you would be, are you sure it is your son? If you have dogs and cats, this seems like more common behavior from the animals than from a seven year old (sometimes kids will admit to things they did not actually do in order to appease adults, so unless you have solid evidence that he is the culprit, the jury may still be out).

But lets assume it is your son, and that there is no medical reason to explain the behavior. A child with impulse control problems, as is associated with some types of ADHD, may simply think without acting. He may just be waiting too long to empty his bladder when he is doing something fun or engaging. He may find himself with an overly full bladder that he can no longer avoid, and may just go on the rug to avoid wetting his clothes. As kids grow, their bladder is sometimes not large enough for them to maintain control as we expect (such as all through the night). If he has a history of maintaining bladder control, than you may just need to help him develop a habit of going to the toilet every hour so that he does not build up to an 'emergency' level of fullness.

Your pediatrician should be able to refer you to a pediatric psychologist who can assist you in determining how to intervene if it is a behavioral issue. A psychologist can design a positive behavior program for you and your husband to implement that will be based on rewards and incentives to reinforce the desirable target behavior (using the toilet). The psychologist can also do an evaluation to determine why this might be happening. With soiling and voiding problems, it is best to get professional help rather than trying to manage them yourself for two reasons. One is that these issues cause a lot of stress for both parent and child, and can snowball into huge issues. Second, this behavior is likely to respond well to treatment from someone who knows what they are doing.

I would not necessarily chalk this up to an aggressive behavior, though I am sure it is very provocative for you. Urinating outside of the toilet is not commonly associated with ODD/CD. Typically kids with ODD or compulsions are anxious about germs and soiling, and would only be likely to avoid the toilet if they have a fear of being contaminated. If he is not avoiding the toilet for bowel movements, then this is probably not related to a germ anxiety, fear of falling in, or fear of the loud flushing sound that bothers some children.

I could see the urination as a compulsive behavior if there was some ritual around it (such as the child believing he has to do so at specific times of day, or if a particular event happens such as a specific commercial coming on TV). Compulsions come with an irresistible anxiety around not being able to do the behavior. In  this case, it would look like him becoming very upset about the idea of not being able to urinate on the rug. Compulsions are associated with anxiety. They typically occur when a child is anxious. The child is generally aware that the behavior is not appropriate, but he can not resist the urge to perform it. Not being able to perform the compulsory behavior is associated with a sense of dread for the child (e.g. if I don't touch the light switch three times, then something bad will happen to me).

So between now and when you speak with the pediatirican, I would back off from trying to intervene behaviorally and collect some data. Keep track of any changes in your son's behavior or mood. Take note of how well he is eating and sleeping. Note when the urination occurs, how often, and how much urine there seems to be (a sprinkle? a full bladder's worth?). Note if your son complains of any physical pain such as burning urination or urgency to urinate. Note if his urine seems cloudy, smelly or even a little bloody. Keep track of if this is happening at school. Ask the teacher if there is anyting going on that might have increased yoru son's stress level at school, ask her to watch over him for a couple days and report back to you.

Until you know that this is behavioral, you should hold off on consequences or having him write in his journal. I would even not discuss it for a couple of days and see if that helps a bit. If it is behavioral, it is much more likely to be driven by his anxiety (bright children are often more anxious than same aged peers) and not aggression. Keep in mind that punishing or interrogating an anxious child is likely to make the situation much worse, so go with a light touch for a while.

Best wishes for you and your carpet!
Rebecca
Disclaimer: This post was written for informational purposes only. It is never intended to replace face-to-face medical or psychological care. This post is not intended to create a patient-clinician relationship, nor to give or rule-out a specific diagnosis.
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Rebecca Resnik, PsyDBlank
MindWell Clinical Psychology
Bethesda, MD
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