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Encopresis – a guideline for parents

Encopresis – a guideline for parents

By Ashley Jay

Definition

Encopresis or involuntary defecation, involves a complicated interplay between physiological and psychological factors. A typical child with Encopresis may show evidence of chronic constipation, leading to infrequent defecation, withholding of bowel movements and avoidance of defecation. Children may often want to avoid the pain of having a bowel movement by holding it in which can lead to impaction and eventual overflow soiling.

Causes

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 behaviour, parental hostility or punitive parenting.

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 also occur in a child who has had a traumatic or frightening experience. When behavior problems occur they are usually due to the interpersonal consequences of soiling. These may include:

  • Parental tension towards the child
  • Peer ostracization
  • Constant rejection or avoidance by others leading to low self esteem
  • The child may be blunted toward the symptoms and use it as a way of expressing anger

The best outcome of Encopresis cases relies on the family and school’s willingness to participate in the treatment and behaviour modification process without being punitive towards the child and by helping to alert the child’s awareness of when they need to go to the toilet.

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 can become large and hard, and attempted passage may result in pain and avoidance of the toilet, which make the situation worse. In severe cases rectal impaction may result, and the watery contents of the higher colon are passed around the retained stool, resulting in involuntary soiling.

Signs & 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 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.

Treatment

The majority of children with Encopresis can be quickly and effectively treated with a combination of medical, psychological and dietary intervention. Various strategies include:

  • Medical examination to rule out the existence of biological causes and to aid in the constipation if any. Substances such as fiber, enemas, laxatives, lubricants, may be recommended to help empty the colon and decrease painful bowel movements in severe cases.
  • Family tensions towards the problem must be reduced and a non-punitive atmosphere established. If this is not done it will just lead to further anxiety for the child and further influence the encopretic cycle.
  • Efforts must be made to reduce the child’s feelings of embarrassment/shame at school (e.g. provide changes of under wear, do not ignore the problem but do not make a big fuss over it either)
  • NB: Under no circumstances is the child to be left in their soiled under wear. They need to be cleaned and changed immediately with as little fuss as possible.
  • Psychological treatment may involves emotional assessments or play therapy to treat  for underlying emotional causes or related anxieties such as low self esteem or social isolation.  Education for the parents and the child about the physiology of encopresis or chronic constipation is also important.

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. Proper bowel habits should be taught. When the cause is presumed to be psychological, consultation with a mental health professional is advised.

Common questions

 How to help preschool children get over habits of soiling their pants, even when they’re in their play group?

Try and establish a regular time every day (after meals is usually best) for them to sit on the toilet and move their bowels. They may need to sit on the toilet several times during the school day. Reward and praise them every time they have a bowel movement in the toilet. If the problem persists, consultation with a mental health professional is warranted.

Do children with limited diets have anything to do with soiling?

Respect their choices, but be sure their 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.

 Are rewards helpful? Won’t punishment make them more aware that they are doing something wrong?

It’s seldom wise to shame or punish a child for behavior that seems to be beyond their 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 source the feelings behind this behaviour and then to help change their behavior.

Regression under stress

Some children, particularly those who had difficulty in this area initially, may regress when they’re under stress. Arrange for them to use the toilet at the same time every day to re-establish their regular routine. Reward them for successes. It would be helpful to make sure that they understand the stressful situation in concrete terms (e.g. Divorce, where they will live, go to school etc) If possible, provide a predictable schedule for other aspects of their life; (e.g. Divorce – make sure they know they will have time with each parent. It is also important to help them understand the separation is not their fault, that they are not being punished and that the parents present a unified front regarding the child’s emotional well being).