La dyschésie psychologique de l’enfant : anxiété, éducation comportementale et TCC

Abstract

L’acquisition de la propreté chez l’enfant est très importante dans notre société, car elle conditionne l’entrée en maternelle. Les troubles du contrôle sphinctérien (encoprésie et énurésie) sont les phénomènes qui entravent cette entrée scolaire. Parmi ces troubles, les cliniciens reçoivent en consultation de jeunes enfants en raison de leur incapacité ou difficulté d’exonération des selles, c’est-à-dire à émettre naturellement des selles. Ce trouble que l’on nomme la dyschésie semble être un phénomène nouveau. Il amène les parents en consultation, souvent après la rencontre d’un médecin généraliste et des examens médicaux dénotant l’absence de problèmes organiques. Nous nommons cette dyschésie qui a alors une étiologie psychique : dyschésie psychologique. L’objectif de cet article, après avoir dressé un état des lieux de la dyschésie, consiste : (1) à spécifier la symptomatologie de la dyschésie psychologique et (2) sur la base d’une étude de cas d’un enfant reçu en consultations, à proposer une prise en charge d’inspiration cognitivo-comportementale. Si sur le plan psychothérapique nous observons les bénéfices de cette prise en charge de la dyschésie (nous avons suivi plusieurs enfants pour ce problème), des recherches épidémiologiques et étiopathogéniques nous semblent nécessaires, pour confirmer ou infirmer les mécanismes qui nous semblent sous-tendre ce problème, et ainsi, améliorer la prise en charge. Toilet training is an important step in the bodily and social development of young children. It is particularly important in France as it can hinder entrance to kindergarten (which is free in France). Children who have not developed sphincter control may be refused admission to nursery school. The most frequent disorders of sphincter control are encopresis and enuresis, for which cognitive and behavioral therapy (CBT) has shown to be efficient. Nevertheless, clinicians see young children for psychological counseling for a different kind of sphincter control disorder: their incapacity or difficulty in evacuating stools, i.e., to naturally pass stools. This disorder which belongs to dyschezia specter seems to be a new phenomenon. It causes parents and their child to seek counseling, often after consultation with a general practitioner and medical examinations confirming the absence of biological problems. We call this particular form of dyschezia, which has a psychological etiology, psychological dyschezia. This article focuses on dyschezia. Firstly, we drew up an inventory of dyschezia from a general point of view. Then, we indicated the mechanism of stool evacuation regarding its normal and pathological aspects. We presented the epidemiological studies which focus on constipation. Finally, we detailed the biological, functional and psychological causes of dyschezia. Secondly, we focused on psychological dyschezia. We defined it as either the incapacity or the difficulty in evacuating stools (difficult or slow evacuation requiring prolonged efforts), or as the retention of stools in the absence of a biological or functional anomaly. In addition, we presented the symptomatology in terms of the criteria allowing a diagnosis. Furthermore, we illustrated this phenomenon of psychological dyschezia with a case study on a child, Maël, who is 4 and a half years old. He was receiving counseling because, since starting nursery school, he has not been able to evacuate stools in the toilet or on the potty, and can only achieve evacuation in his diaper. Prior to kindergarten, he had no particular problem and was able to evacuate stools normally. We presented the functional analysis of the behavior problem, the etiopathogenic hypotheses (stress bound to the context change from home to nursery school and fear of pain during the push) and psychotherapeutic hypotheses (management of stress bound to the nursery school, learning how to push, deconditioning of the fear of pain during the push). The therapy was developed around two axes: psycho-education and CBT. The psycho-education part aimed at teaching the child the normal mechanism of evacuation. It was also a question of understanding if the child perceived the cues indicating the need for evacuation and, if so, how he reacted. The cognitive-behavioral part used materials: figurines and a miniature house. On one hand, it focused on learning how to push at the level of the stomach by means of a figurine symbolizing the child. On the other hand, it investigated the psychological world of the child and the need to decrease toilet anxiety and the fear of pain during the push. On a psychotherapeutic level, we observed the clinical benefits (we followed several children for this problem) as Maël can now pass stools normally. It is therefore necessary to set up epidemiological and etiopathogenic research to confirm or invalidate our hypotheses on mechanisms that seem to underline this problem, in order to improve the therapy.