Encopresis & enuresis in children: the CBPT assessment & treatment protocol
A practitioner’s guide to recognising and treating toileting difficulties in childhood with Cognitive Behavioral Play Therapy, alongside medical care — under the scientific direction of Maria A. Geraci and Susan M. Knell.
Train in the CBPT protocol for elimination disordersScientific direction: Maria A. Geraci and Susan M. Knell
Five-phase clinical pathway
For child psychotherapists
Toileting difficulties are rarely about willpower. When shame is replaced with structure and play, the body can relearn what it forgot.
— CBPT Research Center
When the body and shame get tangled
Elimination problems are among the most distressing and least talked-about childhood difficulties.
A child who soils or wets — by day or night — often feels shame, hides accidents and withdraws, while parents oscillate between worry and frustration. Once medical causes are addressed, the emotional and behavioural cycle frequently sustains the problem.
“I try to hold it, and then it just happens — and I don’t want anyone to know.”
Understanding elimination disorders in children
A clinical overview: what encopresis and enuresis are, how their symptoms present, when they begin, and the factors that cause and maintain them.
Elimination disorders (DSM-5-TR): encopresis & enuresis
Repeated inappropriate elimination of faeces (encopresis) or urine (enuresis) causing distress or impairment
Encopresis: chronological/developmental age ≥4 years; Enuresis: age ≥5 years
Essential first step to identify and treat constipation, UTIs or structural causes before psychological formulation
Shame, social withdrawal and low self-esteem are common accompaniments regardless of subtype
Both conditions respond well to combined medical and behavioural approaches
What are encopresis & enuresis? (DSM-5-TR definitions)
Encopresis and enuresis are elimination disorders defined by repeated inappropriate passage of faeces or urine beyond the expected developmental age.
Encopresis is characterised by repeated passage of faeces in inappropriate places (e.g., clothing or the floor), occurring at least once per month for at least three months, in a child of chronological or developmental age of at least four years, and not attributable solely to the physiological effects of a substance or another medical condition (although constipation with overflow incontinence is a common finding). Enuresis is characterised by repeated voiding of urine into bed or clothes, occurring at least twice per week for at least three months, or causing clinically significant distress or impairment, in a child of chronological or developmental age of at least five years, and not attributable to the physiological effects of a substance or another medical condition. Enuresis is further specified as nocturnal only, diurnal only, or both.
Both conditions frequently carry a significant emotional burden: the child may experience shame, seek to conceal accidents and progressively withdraw from social activities. Medical assessment to identify and address contributing physical factors is an essential prerequisite for psychological formulation and intervention.
Symptoms & presentation
Both encopresis and enuresis present with characteristic patterns that vary by subtype and developmental context.
In encopresis, the clinician may observe soiling episodes (often reported by caregivers rather than the child, who may conceal them), constipation and overflow incontinence, withholding behaviour, avoidance of toilets or specific toileting situations, and accompanying anxiety or oppositionality. In enuresis, the pattern is defined by timing: nocturnal wetting during sleep, daytime wetting (diurnal), or both. Across both subtypes, common clinical features include:
- Soiling or wetting episodes not accounted for by a medical condition alone
- Withholding and constipation (particularly in encopresis)
- Nocturnal vs. daytime patterns (enuresis)
- Avoidance of toilets or refusal to use them
- Secrecy and concealment of accidents
- Social withdrawal and low self-esteem
What is developmentally expected
Bladder and bowel control develops along a range; the diagnostic age thresholds distinguish disorder from normal developmental variation.
Toilet training is a developmental milestone that unfolds across a wide range of ages and is influenced by biological maturation, family context and individual temperament. Occasional accidents are normative in young children who are still consolidating bowel and bladder control. The DSM-5-TR diagnostic thresholds — chronological or developmental age of at least four years for encopresis, and at least five years for enuresis — provide a clinically grounded benchmark for distinguishing presentations that warrant assessment from those that fall within the expected range of development. Clinicians should consider the child’s developmental level rather than chronological age alone when interpreting the significance of toileting difficulties.
Differential diagnosis & medical assessment first
Medical evaluation is an essential prerequisite to identify and treat physical contributors before psychological formulation and intervention.
- Functional constipation with overflow: one of the most common contributors to encopresis; constipation must be identified and treated medically before behavioural and play-based work can be effective.
- Urinary tract infections (UTIs): a common medical cause of diurnal enuresis in girls in particular; must be excluded or treated before psychological intervention.
- Structural or neurological causes: rare but important to exclude via paediatric evaluation when the presentation is atypical or resistant to standard approaches.
Common comorbidities
Elimination disorders in childhood frequently co-occur with anxiety disorders, ADHD and oppositional behaviour. The secondary emotional impact — shame, low self-esteem and social withdrawal — is itself a significant area of clinical focus regardless of the primary subtype. Assessment should encompass the child’s broader emotional and behavioural functioning so that the clinical formulation and treatment plan address the full picture.
Onset, course & epidemiology
Enuresis is more common and more frequent in younger children, decreasing with age; encopresis frequently involves functional constipation.
Enuresis is one of the more prevalent elimination concerns in childhood, particularly in younger age groups, with prevalence decreasing as children mature. Nocturnal enuresis is more common than diurnal. Encopresis is less prevalent and more often associated with functional constipation and overflow incontinence. Both conditions show a tendency toward natural resolution over time, but for a significant proportion of affected children the difficulties persist without targeted intervention. The emotional and social consequences — shame, peer avoidance, family conflict — can accumulate over time and become a source of impairment in their own right, which is why early and integrated care is clinically indicated.
Causes & maintaining factors (CBPT conceptualization)
Physiological factors interact with learned avoidance, anxiety and the shame–secrecy cycle to maintain elimination difficulties.
Elimination disorders are best understood through a biopsychosocial lens. Physiological factors include functional constipation (which may produce overflow and distort the child’s awareness of rectal fullness), sleep arousal thresholds in nocturnal enuresis, and bladder capacity or maturation. These physical factors interact with behavioural and psychological factors: the child learns to avoid or suppress signals, anxiety around toileting increases, and accidents are managed through secrecy rather than disclosure. Parental responses — even well-intentioned ones — can inadvertently reinforce avoidance or add shame to an already distressing cycle.
In the CBPT conceptualization, the key maintaining mechanism is the interaction among the physiological substrate, the learned avoidance and the emotional load (shame, embarrassment, anxiety). CBPT — coordinated with medical management — addresses the behavioural routine (scheduled toileting, reinforcement systems), the emotional dimension (de-shaming, building motivation and confidence), and parental responses, helping both child and family develop a matter-of-fact, non-punitive approach that allows the body to relearn what it needs to learn.
The CBPT treatment protocol
A structured, brief and goal-oriented pathway for delivering cognitive behavioral therapy for elimination disorders through play: from shared therapeutic goals, through the child’s five-phase work with behavioural routines and shame reduction, to the parallel parent-training track and the change clinicians can expect to see.
Therapeutic goals
CBPT is well suited to elimination disorder treatment because it addresses the behavioural routine, the emotional load and parental responses through play.
In CBPT, goal-setting is shared with the child and family. The aim is to teach skills that help the child understand, think about, interpret and respond effectively to events — escaping the negative thought-and-behaviour patterns that drive and maintain toileting difficulties. In the context of encopresis and enuresis, the protocol generally pursues:
- developing emotion-regulation capacities;
- direct teaching of anxiety-management and self-regulation techniques;
- developing problem-solving skills;
- psychoeducation for both parents and child.
Crucially, both parents and child should start from the awareness that the child is not responsible for the disorder, that symptoms are separate from who the child is, and that all stakeholders — parents, teachers and therapists — share responsibility for addressing the current struggles.
Working with the child — phase by phase
The intervention is organised into five sequential phases, from orientation to follow-up.
Orientation Phase
The initial phase of CBPT places significant emphasis on preparing both the child and the parents. An initial meeting between therapist and parents — without the child — reviews the child’s history and background in detail and lets parents share their perception of the problem. In this phase, the therapist begins to de-shame the problem and builds a matter-of-fact, playful language for the body that will carry through the entire treatment. The therapist helps parents prepare the child for the first session and explains the ongoing role of parents and other significant adults across assessment and treatment.
Assessment Phase
This phase collects the information needed to establish shared, goal-oriented therapy targets. Beyond interviews with parents, structured observation of the child’s play is a key element. The assessment establishes a baseline of toileting episodes, the child’s routine, constipation patterns and triggers, coordinating findings with the medical evaluation. Tools include questionnaires administered to parents, assessment of the child’s play, a puppet sentence-completion task that lets the child reveal thoughts and feelings indirectly, and other measures personalised by the therapist.
Case Conceptualization Phase
CBPT analyses the data gathered during assessment to plan effective treatment and provide a logical structure for developing and achieving goals. For elimination disorders, this means mapping the physiological, behavioural and emotional contributors specific to this child: the interplay between constipation or arousal thresholds, learned avoidance, anxiety around toileting, and the shame–secrecy cycle, alongside protective and risk factors in the family environment.
Intervention Phase
This phase uses CBT techniques to help the child develop more adaptive responses to problems, situations and stressors, emphasising adaptive thoughts and behaviours. Scheduled toileting, reinforcement systems, anxiety reduction and coping with accidents are rehearsed via play: drawing, therapeutic storytelling, puppets and role-play allow the child to practise new routines and responses in a safe, shame-free context. Methods include modeling, bibliotherapy, generalisation and relapse prevention, with explicit work on carrying learned behaviours into home and school life. Regular parent meetings continue to monitor progress.
Conclusion Phase
Both child and family are actively involved in the final phase. The work consolidates routine and confidence, relapse-prevention planning fades the therapeutic support gradually, and the child addresses feelings related to ending therapy while the therapist highlights the changes achieved. Final sessions may be spaced from weekly to biweekly or monthly. Positive reinforcement is provided for progress between sessions and the separation is normalised. Follow-ups are scheduled at 3, 6, 12 and 24 months to verify the effectiveness of the intervention.
Learn to deliver every phase in session
Master the five-phase clinical sequence with the child — the play-adapted CBT techniques, behavioural routines and reinforcement systems, the in-session sequencing and the assessment battery — under the scientific direction of Maria A. Geraci and Susan M. Knell.
Get the complete in-session protocolThe structured 16-week treatment protocol
For elimination disorders, the protocol is typically organised across roughly 16 weeks, individualised to the child’s pattern and medical status.
Each session follows a consistent structure: review of the previous week, reaffirmation of goals, presentation of new information, selection of intervention targets, practice of relapse prevention, and assignment of homework for the following week. A common arrangement integrates:
- Early sessions — psychoeducation, de-shaming and establishing a matter-of-fact language for the body;
- Mid sessions — introduction and rehearsal of scheduled toileting routines, reinforcement systems and anxiety-reduction strategies through play;
- Ongoing — coordination with medical management; parent sessions to embed non-punitive routines at home;
- Later sessions — consolidation of confidence, coping with occasional setbacks, and relapse prevention;
- Final sessions — gradual tapering and conclusion, with follow-ups at 3, 6, 12 and 24 months.
The intervention is reinforced by a Playbook: a family resource of weekly play-based activities, a copy of the treatment plan and the therapeutic agenda, plus worksheets to monitor toileting patterns and track progress. The Playbook becomes the family’s transitional object, carrying therapy skills into the child’s everyday world.
Working with the family — parent training
While the child follows the five-phase CBPT protocol, parents follow a parallel five-phase training programme.
A competence-based pathway brings parents into the playroom to shape adaptive behaviours.
Parent Training is a competence-based intervention model that assumes families are capable of managing the problem, that every family has strengths, and that parents can learn new skills. Integrated into CBPT, it brings parents into the playroom to observe and progressively implement interventions that shape adaptive behaviours in the presence of the therapist, aiming to modify relational styles and attitudes that negatively affect children’s behaviour.
Parents are taught to understand the factors contributing to the child’s symptoms, the cues and events that trigger difficult moments, and behaviour-management strategies that enhance self-esteem rather than shame the child — alongside the principles of a collaborative problem-solving approach (Greene) that respects both the parent’s and the child’s point of view.
Through this approach, parents have the opportunity to:
- Learn new skills.
- Acquire and practise specific techniques.
- Receive individualised, ongoing feedback from the therapist to increase their awareness.
- Interpret more accurately their children’s emotions, concerns and communication expressed through play.
This program, called PARENT TRAINING CBPT, follows an integrated and innovative approach. Although the primary work is with the child, periodic meetings with parents are essential during both assessment and treatment: this pathway runs parallel to the child’s therapy, emphasising the role parents play in influencing maladaptive behaviours. Parents are encouraged to reinforce adaptive child behaviours so treatment continues outside the therapy setting (using appropriate reinforcement for adaptive behaviours and extinction for maladaptive ones).
The parent-training pathway — five phases
Assessment
The problem is analysed, parenting style is adapted and therapeutic goals are defined. Parents receive information about the causes and consequences of their child’s dysfunctional behaviours and learn to establish clear, consistent rules.
Learning
This phase teaches the new skills needed to support change. Parents learn and practise specific techniques through role-play sessions in which the therapist acts as the child. Key targets include:
- mastery of prerequisites;
- modeling of skills;
- role-playing;
- errorless learning;
- successive approximations (shaping);
- feedback (verbal and social reinforcers, token economy);
- repeated practice.
Practice
Parents carry out play sessions with their own children to apply the skills learned, recognising and preventing situations that trigger difficult behaviours and using consistent problem-solving strategies across contexts. After initial practice with the therapist, parents begin to run individual play sessions under supervision.
Review
Parents discuss at length with the therapist the home play sessions to learn how to generalise what they have learned. Strengths and any problems are reviewed; the therapist helps generalise the interventions and parenting skills acquired. Each week, time is dedicated to applying techniques in everyday life and homework is assigned to practise the strategies.
Conclusion
Reached when therapeutic goals have been met and parents have achieved a satisfactory level of competence in play activities and parenting skills. Therapy is tapered gradually, reducing session frequency to every other week, then monthly, and so on.
Objectives of parent training — specific goals
This program helps parents interact effectively with their child by developing functional behavioural and communicative habits and techniques, removing the conditions that give rise to problem behaviours and replacing them with adaptive, socially desirable conduct.
Understanding behaviour
Increase understanding of the child’s problematic behaviour.
Realistic expectations
Set more realistic expectations.
Warmth & acceptance
Increase warmth, trust and acceptance toward the child.
The value of play
Recognise the importance of interaction through play.
Effective communication
Communicate more effectively with their children.
Parental confidence
Develop greater confidence and reduce frustrations experienced with their children.
Patience
Cultivate greater patience to create more realistic expectations.
Self-understanding
Discuss personal reactions with the therapist to understand their own feelings and behaviours.
Problem solving
Become effective problem solvers of family conflicts and develop stronger motivation for change.
The course includes the full parent-training pathway
Deliver the integrated parent-training track alongside the child’s protocol — the five parent-track phases, the competence-based model and the Playbook structure that carries change beyond the playroom.
Start the Elimination Disorders in Children courseWhat change looks like
As the child builds a consistent routine and shame gives way to confidence, toileting difficulties loosen their grip.
Through structured routines and anxiety reduction delivered in play, the child learns that accidents can be managed without shame and that the body can be trusted again. As emotion-regulation and problem-solving skills grow — and with parents supported throughout — progress reaches beyond the therapy room into home and school life, with follow-ups confirming that the gains hold.
Train in the full assessment-and-treatment protocol for elimination disorders in children.
Train in the CBPT protocol — Elimination Disorders in Children courseEncopresis & enuresis: clinical FAQ
Why is medical assessment a prerequisite before starting CBPT?
Constipation with overflow incontinence, urinary tract infections and structural or neurological causes must be identified and treated before behavioural and play-based work can be effective. CBPT complements medical care rather than replacing it: the psychological and play-based components address the behavioural routine, the emotional load (shame, anxiety, motivation) and parental responses, but these interventions are built on a foundation of adequate medical management. The training details how to coordinate with the paediatric team within the CBPT framework.
How does CBPT add value beyond behavioural charts?
Behavioural charts and star charts are useful tools, but they do not address the shame, anxiety and avoidance that frequently maintain elimination difficulties once they become established. CBPT targets the emotional dimension directly — de-shaming the problem, building the child’s confidence and motivation, and engaging them through play rather than through pressure or performance expectations. This makes the child an active participant in change rather than a passive recipient of a monitoring system.
What is the family’s role in the CBPT protocol?
Parents play a central role throughout the protocol. They follow a parallel competence-based training pathway in which they learn non-punitive routines, reinforcement strategies and consistent problem-solving approaches that reduce conflict around toileting at home. The training helps parents respond to accidents in ways that reduce shame and maintain the therapeutic gains achieved in session, so that change generalises into everyday family life.
Are encopresis and enuresis treated the same way?
The CBPT framework is shared — de-shaming, scheduled routines, reinforcement systems, anxiety reduction, parent training — but the intervention is tailored to the specific subtype and the individual child’s profile. Constipation management is central in encopresis, and the medical and behavioural work are closely coordinated. In nocturnal enuresis, sleep arousal, fluid scheduling and alarm protocols feature alongside the play-based emotional work. The case conceptualisation phase maps the specific contributors for each child to guide this tailoring.
How long is treatment?
The protocol is organised across roughly 16 weeks and is individualised to the child’s progress and medical status. Many children improve substantially with combined medical and behavioural care within this timeframe, though some cases benefit from a longer or more graduated approach. The structured five-phase pathway, Playbook and follow-ups at 3, 6, 12 and 24 months provide a framework that can flex to the child’s needs while maintaining clinical consistency. The training covers how to adapt the protocol for different presentations.
Train in the full protocol
Master the complete CBPT assessment-and-treatment protocol for elimination disorders in children — five clinical phases, behavioural routines and anxiety reduction through play, and the parent-training pathway.
Enrol in the Elimination Disorders in Children courseBibliography
The clinical framework, assessment battery and phase-by-phase protocol described above are grounded in the CBPT literature and in DSM-5 / DSM-5-TR, under the scientific direction of Maria A. Geraci and Susan M. Knell.
- American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).
- Geraci M. A. (2022). La play therapy cognitivo-comportamentale. Armando Editore. Roma
- Geraci M. A. (2023). Comprendere il mondo dei bambini giocando. Armando Editore. Roma
- Geraci M. A. (2024). Il mondo della dottoressa Lulù. Collana Amazon - CBPT Books.
- Greene, R. W. (2014). The Explosive Child (collaborative problem-solving approach).
- Knell S. M. (1993). Cognitive Behavioral Play Therapy. J. Aronson.
CBPT Research Center — Training Programme
Professional Training in CBPT for Elimination Disorders
The CBPT Research Center develops and delivers evidence-based postgraduate training for psychologists, psychotherapists and clinical specialists. Our certified curriculum includes a dedicated module on the CBPT approach to Elimination Disorders, grounded in peer-reviewed research and clinical practice.
View the training curriculumThe in-session protocol
Skills you can apply in session — under the scientific direction of Susan M. Knell, originator of CBPT.