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About Encopresis

Toileting issues are of great concern to many parents and can be source of family stress. Identification and appropriate treatment of a child's elimination disorder can help parents avoid ongoing disagreements and forestall behavioral or emotional problems. Many factors interact to cause elimination disorders - mastery of urine and bowel control is affected by a child's maturational level, intellectual capacity, cultural customs, and the dynamics of the parent-child relationships.

Encopresis refers to soiling with no organic basis. A child with encopresis passes feces into inappropriate places, such as underwear or the floor, after the time that bowel control is physiologically possible and after the age at which toilet training is expected to be accomplished.

Introduction

Some children, in the process of toilet training, may have difficulty in mastering bowel control and have accidents in their underwear. By the age of four, if accidents occur at least once a month for three months and are not due to a physical abnormality or general medical condition, the child is considered to have encopresis. There are two basic categories of encopresis: a) primary - which refers to children who have never attained bowel control and b) secondary - children who begin to soil again after attaining control.

Real Life Stories

James, aged 5, had no difficulty in attaining urinary control but bowel control was inconsistent and never completely accomplished. He refused to sit on the toilet and resisted his parents' repeated efforts, which varied from cajoling to punishment. When James entered preschool he seemed to adjust well initially, but after a few months his teacher noted that his underpants were often soiled and the other children didn't want to play with him. When she brought this to his attention, James became embarrassed, started to cry and then resisted going on the school bus.

Marissa, aged 4 l/2, mastered bowel control without incident before the age of 3, but then began to soil again and to suck her thumb, much to the consternation of her mother. After numerous unsuccessful attempts to help Marissa regain control, her mother sought professional advice. After a meeting with the family, it was discovered that the soiling and other regressive behaviors were related to Marissa's reaction to the argumentative relationship between her parents and their recent decision to separate.

What are the symptoms?

Most often encopresis is involuntary, but occasionally may be intentional. When it is involuntary, the child usually withholds his stool, often because he is constipated and therefore experiences pain when he has a bowel movement. The stool then becomes harder and even more painful to pass. In severe cases, a large amount of dry stool becomes impacted in the rectum and watery feces leaks out, soiling the child's underwear. The retained feces results in large masses of stool that can dilate the colon, causing megacolon.

Subtypes (according to DSM IV)

Subtypes of encopresis are defined according to the following characteristics:

• With Constipation and Overflow Incontinence: There is evidence of constipation on physical examination or by history. Feces are characteristically (but not invariably) poorly formed and leakage is continuous, occurring both during the day and during sleep. Only small amounts of feces are passed during toileting, and the incontinence resolves after treatment of the constipation.

• Without Constipation and Overflow Incontinence: There is no evidence of constipation on physical examination or by history. Feces are likely to be of normal form and consistency, and soiling is intermittent. Feces may be deposited in a prominent location. When this occurs, it is usually associated with the presence of Oppositional Defiant Disorder or Conduct Disorder and may be the consequence of anal masturbation.

Who is likely to have it?

In western cultures, bowel control is established in more than 95% of children by the age of 4, and 99% of children by the age of 5. Encopresis occurs in about l% of 5-year-olds. By age l0 or 12 once-a-month soiling occurs in 1.3% of boys and .3% of girls. It is five times more common in boys than in girls and 25% of children with this problem are also bed-wetters. Although long-term studies have not yet been done, clinical experience suggests that encopresis is self-limiting, rarely occurring beyond adolescence.

Why does it happen?

The primary cause of encopresis is unclear. A variety of explanations have been proposed - psychological, anatomical, physiological and dietary - but the most likely explanation is that the causes of encopresis are multifaceted. Most children with encopresis do not have a physical abnormality that interferes with their ability to gain bowel control. Some children may intentionally withhold for psychological reasons; they may fear using the toilet or the withholding may be due to a pattern of oppositional behavior.

In many cases encopresis occurs when there is a stressful family situation, such as divorce, birth of a sibling or a transition such as starting school. When a child actually smears feces, there is a strong indication that there may be a problem in family relationships. The child who is reluctant to openly express anger may express it by soiling. Soiling may occur in a child who has had a traumatic or frightening experience, such as sexual or physical molestation. When behavior problems occur they are usually due to the social consequences of soiling.

The physiological basis of encopresis is chronic or intermittent retention of feces, resulting in distension of the rectum and colon leading to a lack of sensitivity for the defecation reflex. The stools become large and hard, and attempted passage may result in pain and avoidance of the toilet, which make the situation worse. Rectal impaction may result, and the watery contents of the higher colon are passed around the retained stool, resulting in involuntary soiling.

Other physiological factors that may contribute to constipation include dehydration due to febrile illness, hypothyroidism, or a medication side effect. Overflow incontinence resulting from constipation can be caused by faulty nutrition, structural disease of the anus, rectum and colon, or endocrine or neurological disorders.

How is it treated?

The majority of children with encopresis can be quickly and effectively treated with a combination of medical, psychological and dietary intervention. Management strategies include a medical examination to rule out the existence of organic causes. Substances such as fiber, enemas, laxatives, lubricants, may be used to empty the colon and decrease painful bowel movements. Initial treatment also involves education of the parents and the child about the physiology of encopresis or chronic constipation. Family tensions regarding the symptom should be reduced, and a non-punitive atmosphere established.

Some children also retain feces and become constipated either voluntarily or secondary to painful defecation. The resulting chronic rectal distention from large, hard fecal masses may cause loss of tone in the rectal wall and desensitization to pressure. Thus the child may become unaware of the need to defecate, and overflow encopresis occurs, usually with relatively small amounts of liquid or soft stool leaking out.

Behavioral techniques, such as star charts and daily diaries, have been helpful in teaching the child a new way to behave and to become attuned to body cues. In some cases, biofeedback techniques have been utilized. Proper bowel habits should be taught. When the cause is presumed to be psychological, consultation with a mental health professional is advised. Depending on the severity, a child may benefit from medication.

Questions & answers

How can we help our four-year-old get over his habit of soiling his pants, even when he's in his play group?

Try and establish a regular time every day (after meals is usually best) for him to sit on the toilet and move his bowels. He may need to sit on the toilet several times a day. Reward and praise him every time he has a bowel movement in the toilet. If the problem persists, consultation with a mental health professional is warranted.

My child has a very limited diet. Could this have anything to do with his soiling?

Respect his choices, but be sure his diet contains enough high fiber which is found in fruits, vegetables and grains. What does constipation have to do with soiling? Children who are constipated may have painful bowel movements or they may not empty their stool completely. For these children, the stool left becomes so large that stool leaks out and produces soiling. Constipation may also result in extreme straining during a bowel movement, pain and bloating, tiredness, loss of appetite between bowel movements, and reluctance to use the toilet.

Rewards just seem like bribery to me. Won't punishment make him more aware that he's doing something wrong?

It's seldom wise to shame or punish a child for behavior that seems to be beyond his control. If you feel your child is soiling as a way of being negative or oppositional, or as a way of getting attention, even if it is negative attention, it would be advisable to consult a mental health professional and find ways to help change his behavior. Other members of the family might be included.

My daughter, who is now five years old, had a problem in learning to control her bowel movements. She was finally successful in establishing good toilet habits, but since my husband and I have decided to separate she's starting to soil again. What can we do?

Some children, particularly those who had difficulty in this area initially, may regress when they're under stress. Arrange for her to use the toilet at the same time every day to re-establish her regular routine. Reward her for successes. It would be helpful to make sure that she understands the new family situation in concrete terms, such as where she will live, go to school, etc If possible, provide a predictable schedule for other aspects of her life; for example, make sure she knows she will have time with each parent. It is also important to help her understand the separation is not her fault and therefore she is not being punished.