Encopresis and Children
Summary of Article
What is Encopresis
Causes of Retentive Encopresis
Causes of Non-Retentive Encopresis
Treatment for Encopresis
Treatment For Retentive Encopresis
Treatment For Non-Retentive Encopresis
What is Encopresis?
Encopresis is defined as the voluntary or involuntary passage of stools (feces) in inappropriate places causing soiling of clothes by a child aged four or over. It is also know as overflow incontinence, bowel incontinence, soiling, fecal soiling and fecal incontinence.Encopresis affects 1 to 3 percent of children and these cases are split into two types:
- Retentive encopresis:
About 80 to 95 percent of all encopresis cases are retentive encopresis. Their stool accidents are mostly involuntary and are not of normal or healthy consistency.
Children with this disorder have an underlying medical reason for soiling.
The remaining 5 to 20% of encopresis cases are functional, or non-retentive, encopresis.
- Non-retentive encopresis
As stated at the end of the retentive encopresis article, the remaining 5 to 20% of encopresis cases have no physical condition that bars normal toileting behaviors. These children aren't constipated and don't seem to have any significant medical problems. They usually soil their diapers or pants almost every day and have normal, mostly voluntary bowel movements.
The main symptom of encopresis is that the child has bowel movements in inappropriate places, such as in clothing or on the floor. This soiling is not caused by taking laxatives or other medications, and is not due to a disability or physical defect in the bowel.
Other symptoms of encopresis may include:
- Avoidance of bowel movements
- Secretive behavior associated with bowel movements.
- Leakage of stool or liquid stool on your child's underwear. If the amount of leakage is large, you may misinterpret it as diarrhea
- Scratching or rubbing the anal area due to irritation from watery stools
- Constipation with dry, hard stool
- Passage of large stool that clogs or almost clogs the toilet
- Loss of appetite
- Abdominal pain
- Decreased interest in physical activity
- Withdrawal from friends and family
Retentive Encopresis frequently results from chronic constipation, which over time results in fecal impaction and in leakage of soft or liquid stool accumulated around the impacted stool or feces. (see Constipation in Toddlers and Children) The leakage may occur during the day or night and it is NOT under the conscious control of the child.
The frequency of leakage varies from infrequent occurrences to a continuous flow. In fecal impactions, feces become impacted in the child's colon, causing it to distend. This causes the child not to feel the urge to defecate.
As a result, the anal sphincter muscle becomes weak and unable to contain the soft stools that pass around the impaction. Despite the constipation, these children actually do have regular bowel movements. However, these bowel movements are often soft and frequently involuntary. The child may not even be aware that he or she has defecated until the fecal matter has already passed.
Many children have a history of constipation that extends back as far as five years before the problem was brought to medical attention.
On the other hand, non-retentive encopresis is a behavioral condition in which the child refuses to poop in a potty or toilet. Children with this condition aren't constipated and don't seem to have any medical problems. They usually soil their diapers or pants almost every day and have normal bowel movements.
Various terms have been used to describe this problem, including functional encopresis, primary non-retentive encopresis, and stool toileting refusal. Characteristics include soiling accompanied by daily bowel movements that are normal in size and consistency. A physiological cause for non-retentive encopresis is rarely identified. The medical assessment is usually normal, and signs of constipation are noticeably absent.
- However, a minute percentage of cases that seem to be non-retentive encopresis do have medical causes, such as:
- irritable bowel syndrome
- severe ulcerative colitis
- acquired spinal cord disease (i.e. sacral lipoma, spinal cord tumor)
- rectoperineal fistula with imperforate anus
- postsurgical damage to anal sphincterŠ
- The child may not be developmentally ready for potty training
- The child may have emotional or behavioral disturbances such as Oppositional Defiant Disorder or Conduct Disorder, or may simply be trying to control their environment in one of the the only ways they can
- The child is afraid. The child will urinate in the potty or toilet, but will refuse to poop in the potty or the toilet.
- Some children will also refuse to poop in the underwear and will only poop in a pull up or diaper.
- Other children will simply refuse to poop at all and end up with chronic constipation.
General treatment for encopresis begins with ensuring that the child in question is having soft, comfortable bowel movements. This alleviates constipation for kids with retentive encopresis, and makes it difficult for children with non-retentive encopresis to resist having bowel movements. Stool softeners and laxatives are a safe, effective way to ensure this. Start with small doses, and gradually increase until the desired effect is achieved.
The optimal treatment regiment for encopresis involves both a medical and a behavioral approach. If a pediatrician makes a diagnosis of retentive encopresis, the physician may recommend laxatives, stool softeners and/or an enema to remove the fecal impaction. The goal is prevent constipation and encourage good bowel habits. A stool softener is often prescribed.
Children should eat a high fiber diet with lots of whole grains, fruits and vegetables. Large amounts of water and regular exercise can help with softer stools and decrease the discomfort associated with bowel movements.
Parents should be supportive and should refrain from criticism or discouragement. Children can be taught to not feel ashamed of the toileting behaviors and psychotherapy can help decrease the sense of shame, guilt and/or loss of self esteem that children may feel.
For the really tough cases, pediatric gastroenterologists use a behavioral method involving biofeedback and video presentations to retrain children who contract, rather than relax their external sphincter muscles during an attempt to make a bowel movement. This method teaches the child not to strain while keeping their anal canal open.
Although the toileting dynamics and behavioral characteristics of children with non-retentive encopresis are well defined, few specific treatment guidelines are available for family physicians, meaning your physician may not be as helpful as you would like!
The American Academy of Family Physicians has 6 guidelines for dealing with this condition.
1: Identify Potential Medical, Developmental or Behavioral Pathology.
2: Address Toilet Refusal Behavior.
3: Ensure Soft, Well-Formed Stools
4: Schedule Prompted Toilet Sits
5: Provide Incentive for Appropriate Bowel Movements and Self-Initiation
6: Arrange for Physician Contact in Case of Stool Withholding.
Before you should come up with a plan to address this issue, it is vital that you and your doctor have done a complete medical evaluation and know for sure that there is no medical reason for your child's encopresis. Š
Once we∆ve ensured that your child is soiling for a non-medical reason, the second thing that needs to be addressed is your child's development. What is the right age for potty training? Is your child developmentally ready to be potty trained?
Not only must your child have the necessary physiological development for potty training(bladder and bowel control), but he needs a degree of motor, cognitive and verbal development that some children don∆t attain until they∆ve reached three or four years, along with a well-developed sense of social conventions. The Potty Training Readiness Signals will help you determine if your child is the developmentally ready for potty training.
The third thing that needs to done is a behavioral assessment. If your child has a pattern of disruptive behavior across multiple settings (such as dressing, bed time, meal time, and others), then their behavior pattern as a whole needs to be addressed before potty training can be specifically addressed. Your child need to be cooperative and compliant to adult instructions and should be able to consistently follow parental instructions in a timely manner.
The last thing that needs to be done is to have daily toileting diary for your child. The diary will help in planning the next steps.
Children with non-retentive encopresis tend to have a history of painful defecation, toilet phobia, and toilet refusal behavior. To overcome these negative associations, you can schedule what the AFP calls "positive toilet sits".
Basically, these are short sessions in which your child sits on the toilet while engaging in a relaxing, enjoyable activity such as reading or talking with you (see our great selection of Children's Potty Training Books).
Your goal during these is to help your child associate the toilet with pleasant, pressure-free situations. Start with very short sits (for example, 30 to 45 seconds) and gradually increase the duration, up to five minutes, preferably using a timer to signal completion.
If your child is extremely resistant to approaching the toilet seat, you can employ what the AFP refers to as a "gradual shaping procedure". Start by modeling appropriate toileting behavior for a few weeks, then begin playing games or reading books with your child in or near the bathroom.
You should then gradually progress to engaging in these activities while your child is sitting on the potty chair, and from there, gradually increase duration. Fathers, it is recommended that you sit while modeling the urinating process.
Before any sort of intervention, it's critical to ensure that your child is having soft, well-formed bowel movements. You may find it necessary to change your child's diet or introduce supplements like flavored fiber drinks or bran sprinkles(see our diet ideas).
If your child still isn't producing soft and well-formed bowel movements, you might want to consider stool softeners or laxatives. On the flip side, these supplements are likely to make it more difficult for your child to withhold their bowel movements, meaning they'll have more soiling accidents.
It's a very good idea to develop a standard clean-up procedure that you can direct your child through and be emotionally neutral about. Don't criticize or blame your child for their mistake.
Once your child is comfortable with the toilet and having comfortably soft and well-formed bowel movements, you can start scheduling prompted toilet sits during which your child is likely to defecate(see our Potty Chairs and Potty Seats).
Schedule prompted sits five to twenty minutes after each meal and during other high-frequency opportunities indicated by your child's daily toileting diary.
Once your child has achieved regular bowel movements on the toilet, you can have a "graduation ceremony" of sorts where you can inform your child that they're now a big boy and diapers will no longer be used. (See our selection of Potty Training Pants)
Don't make the mistake of using diapers when convenience seems to necessitate it (e.g. family outings). This sends a mixed message to your child about toileting expectations.
Once your child has proven that he or she is capable of using the restroom for bowel movements, it's possible to use an incentive program to reinforce appropriate potty behavior. Incentives are most effective when they're age-appropriate and consistently and promptly given after every occurrence of the desired behavior.
Whatever the incentive (candy, stickers, other temporary rewards, and even special time with parents or peers are possible ideas), access to it should be restricted whenever proper toileting behavior has not been exhibited.
Once your child is using the toilet regularly, you'll want to gradually cut down on verbal prompts to use the bathroom, train the child to be aware of the need to urinate or defecate and request to use the bathroom, in order to ensure that your child is using proper hygiene.
In case your child continues to withhold, you should arrange to contact the physician if your child withholds for four consecutive days. Your physician will likely prescribe a daily regimen of laxatives or stool softeners, like in guideline 3.
If withholding leads to impaction, enemas, suppositories, mineral oil, and electrolyte solutions are all possible solutions. Once the impaction is eliminated, your child can return to their daily regimen of stool softeners or laxatives.
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Very informative review.
Our son is 9 years old and has encopresis,we found this web site very helpful.
We would like to know more about behavior in children who have encopresis, and how children and behavior relate to learning and school environments.
Our family is at a loss as to why his behavior is so disruptive at school.