About Dr. Baruch Kushnir
In 1976, I was approached by Dr. Ian Berg (then Head of the Children’s Ward at High Royds psychiatric hospital in West Yorkshire, UK). He suggested I carry out a study for my thesis toward a clinical psychology degree at his department.
He’d seen a recurrent phenomenon—referrals from pediatricians seeking urgent hospitalization for children around the age of ten with a prolonged history of severe encopresis. (Encopresis is the voluntary or involuntary passage of feces outside of the toilet in children, after an organic cause has been excluded). The kids would avoid elimination and suffered appalling constipation. All these issues had caused the children to be socially rejected, and their families were typified by anger, quarrels, violence, and total helplessness in dealing with the problem.
The ward was a paradise for children. It was a cozy, indulgent setting, with dedicated, affectionate staff, a top-quality nursery school and school plentiful of books and toys, and a variety of fun occupations for the young patients. At that time, every hospitalized child started the diagnostic stage with a preliminary observation procedure before any therapeutic intervention. A diagnosis was only given after that stage. Later on, a remedial program was prepared. Surprisingly, in all those cases, after a few days of hospitalization, the child’s encopresis disappeared and didn’t recur throughout the observation period. Their behavior was completely normative. So, three weeks later, they were discharged and returned home without any professional treatment.
Back home, though, the problem reappeared. Dr. Berg believed the topic should be studied in greater depth, and that’s where I came in.
I tracked four children: observed them in their homes, interviewed their parents and schoolteachers, and administered psychological tests. Ultimately, I realized that the issue was far from clear. It had to be explored in depth, and with a larger group of children.
My thesis supervisor was Mrs. Dorothy Fielding, who was researching therapeutic methods for bedwetting for her doctoral studies. It was a fine opportunity for me to get to know the potential of the Bedwetting Alarm method as a solution for the bedwetting problem.
After seven years’ research and specialization in the UK, I returned to Israel in 1978. My clinical work focused on implementing the cognitive-behavioral approach to treat problems associated with anxiety and obsession in adults, and behavioral disturbances in children. At the time, I didn’t think my expertise would eventually focus on sphincter control problems in children.
Occasionally, I was asked to help with bedwetting children. At some point, I took two Bedwetting Alarms I’d brought back from the UK, still unopened, and started using them with my young patients. Very soon, I realized how effective the Bedwetting Alarm was, and saw the huge demand for treating the issue. Time went by, success grew, and more and more young patients were referred to me. The number of clinics and professionals I brought on board was soaring. So far, by 2019, we’ve treated 40,000 children in fifteen clinics across Israel. In tandem with therapeutic work, we carry out research in collaboration with universities in Israel and the US.
It turns out, once you become the Number One expert in bedwetting issues, people also seek your help in constipation and soiling problems! Although wetting problems and pooping problems are “neighbors,” I saw them as two different areas, and I referred people to other specialists.
Then, in the summer of 1987, I changed my approach. The parents of Ari (a boy of 11) came to the clinic. For years, he’d suffered bouts of constipation that could last two weeks or more. Every day he had to change his underpants several times. He was incapable of having a bowel movement on the toilet. He did his best to avoid pooping at all. He could never attend social events because the odor he gave off was unbearable, and he was socially rejected. At home, the situation was like a never-ending catastrophe. Yet his family showed him so much understanding, empathy, and love. Ari’s parents had contacted all sorts of specialists; he’d been examined by expert physicians and a gastroenterologist who ruled out any physiological cause. Dozens of intervention methods—medical and psychological—had been tried, but nothing helped.
An immediate solution was vital.
I’m an expert on bedwetting, but wasn’t totally familiar—and certainly lacked experience—with treating bowel movement problems, definitely in such an extreme case.
The severity of the problem and the family’s unhappiness strongly impressed me. I recalled that long ago, I’d done some research in the UK in the field of bowel movements. But I hadn’t studied the subject in depth and felt I couldn’t offer solutions.
So, I decided to dig deeper, explore the professional literature, and come up with creative ideas for treatment.
A month later I called Ari’s parents to run an idea past them. I told them I had no experience and couldn’t promise it would succeed, but there was little to lose. It was my first attempt at applying my intensive treatment method, which combines the use of enemas with daily phone help for the parents. I presented Ari’s parents with my theoretical model and its rationale and told them exactly what to do. They followed my instructions with accuracy and determination, and never missed our daily call. In just three weeks, to everyone’s delight, the problem disappeared completely and Ari became a regular child. Many families contacted me later with problems of constant constipation, withholding, soiling, and toilet anxiety.
Some parents were thrilled to receive instructions for the treatment. Many, however, were deterred by the idea of using enemas. Yet, as I went deeper into the issue, and gained more experience, I realized that in bowel movement issues there’s not just one type of problem. There isn’t just a single, homogenous group of kids with elimination problems. I pinpointed three different groups, each with specific characteristics, each with its own history and causes:
- Toilet anxiety
- Soiling plus severe and prolonged constipation and withholding.
On the basis of this understanding, I created a unique therapeutic intervention program for each group, which I’ve described in detail in this book. I learned that most kids who suffer from problems related to bowel movements are in the first two categories for which treatment is relatively simple. The only tools needed are:
- The parents’ basic understanding of the problem and
- Applying simple behavioral instructions—in terms of what to do and what not to do; and also what to say and what not to say.
For the third, more complex group, therapy is more complicated and involves the use of micro-enemas, but in most cases, it totally solves the problem.
The professional literature describes various behavioral programs and indeed many of you may have tried methods involving positive rewards, hoping to influence your kid to change his behavior. In many cases, those methods work, but not in all. My approach is different in its nature, in its practical content, and in its basic perception that the problem stems from a source of deep anxiety. Enemas are also often recommended by various professionals; however, they are used for clean-out purposes for a few days. In most cases, they result in temporary relief before the problem recurs. Here again, my approach is different. The use of enemas is aimed at relieving anxiety and is applied in a program of gradual dosage reduction to lead the child to complete, regular, independent use of the toilet for defecation. If you’d like to read more about treatment methods for encopresis, Stephen Borowitz’s extensive review is a good start (Borowitz, S. M. 2017).
It’s clear from my clinical impressions and reports from all the families I’ve treated in recent years that these treatment methods are highly effective.
Every course of treatment conducted in my clinics starts with a brief preliminary phone diagnosis and then continues with a meeting with the parents (without the child) at the clinic.
At the first meeting, I check if pediatricians and/or other specialist physicians have ruled out organic factors. The parents describe the problem, its history, any treatments tried so far, the communication dynamics between parents and child (and maybe with other family members and/or teachers and the child). They tell me about the kid’s personality, character, and level of functioning in different areas. During the meeting, I identify which diagnostic group the child is in, put together a behavioral intervention program for the parents, and give them detailed instructions on how to apply it at home. Back at home, the parents implement the program, following the clinic’s instructions, and of course, they receive unlimited phone support.
After the great success of this therapeutic approach, I thought it important to present all the details of my work in book form. Families across the world can now get a first-hand impression, and then put my ideas into practice to solve their child’s persistent, frustrating problem. It won’t be the same experience as attending an actual meeting at our clinic with phone support. Yet I believe the profound and detailed information I share with readers is really valuable and can contribute to solving the problems they face.
A major insight I’ve gained from my work is that many problems are created and worsened by parents’ incorrect behavior, bad advice from professionals, and a basic lack of understanding of the child’s problem. Maybe you’ve made mistakes. That’s okay because now you’re going to learn how to resolve them. I strongly recommend that you carefully read Chapter 5, which describes my insights into potty training children. It gives a list of recommendations for managing the first stages, which will prevent the creation and worsening of problems.
1970—B.A. Psychology and Sociology, Hebrew University of Jerusalem, Israel
1972—M.Sc. Industrial Psychology, Hull University, UK
1975—Ph.D. Medical Psychology, Hull University
1977—M.Sc. Clinical Psychology, Leeds University, UK
Publications and productions
1991, Bed Wetting—Family Guide, Dr. Baruch Kushnir, Daria Publishing (in Hebrew)
2007, Potty-Training Course, Israeli Television—The Parents’ Channel. A three chapter comprehensive program that relates to numerous potty-training issues.
2008, The Magic Bowl. Animated potty-training musical (In English and Hebrew on DVD and in the mobile Appstore and Play Store).
2011, The Magic Bowl—Potty Training Made Easy—Parent’s Guide, Price World Publishing (included with the book is the DVD of The Magic Bowl movie).
2011, Cognitive Behavioral Therapy for Children—Therapeutic Principles, Mor, N., Mayers, Y., Marom, S., Gilboa, Schechtman, E, (editors). The chapter on Bed-Wetting, Causes and Treatment by Dr. Jonathan Kushnir and Dr. Baruch Kushnir.
Cohen-Zrubavel, V., Kushnir, B., Kushnir, J., Sadeh, A. Sleep and sleepiness in children with nocturnal enuresis, Sleep, 2001, 34(2):191-194. 20
Kushnir, J., Kushnir, B., Sadeh, A. Children treated for Nocturnal Enuresis:
Characteristics and trends over a 15-year period. Child and Youth Care Forum, 2013, 42(2), 119-129.
Kushnir, J., Cohen-Zrubavel, V., Kushnir, B. Night diapers use and sleep in children with
Enuresis. Sleep Medicine, 2013, 14(10), 1013-1016.