Child Encopresis: An Incontinence Problem
Encopresis in Children: A Psychological or Medical Problem
Encopresis in Children is a biological and/or psychological condition that carries both a medical and behavioral diagnosis. Encopresis is characterized by defecating fecal matter in an atypical and socially unacceptable manner. This condition often affects preadolescent children or developmentally challenged individuals.
Medical vs. Psychological Diagnosis
A medical diagnosis of encopresis means that there is an organic, biological condition causing inappropriate passage of feces. Such conditions include severe constipation, gastrointestinal conditions or poor sphincter muscle strength. A psychological diagnosis is made only after all biological causes are ruled out. Sexual abuse, stress, defiance, attention-seeking behaviors and trauma can contribute to encopresis in children. This condition often affects preadolescent children or developmentally challenged individuals.
Encopresis DSM-IV Criteria
According to the “Diagnostic Statistical Manual – Fourth Edition,” the diagnostic criteria for encopresis in children includes:
- Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntarily or unintentional
- Occurrence of at least one such event a month for at least three months
- Chronological age of the child is at least four years (or equivalent developmental level)
- Child’s behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation.
According to Christopherson and Mortsweet, behavioral assessment for encopresis in children should include: 1) an assessment of the child’s toilet training history, including the age the child was trained, the length of training, and the methods used, 2) an evaluation of the previous treatments implemented for your child’s soiling and/or constipation, and 3) a standardized behavior-rating scale on the child’s behavior filled out by both a parent/guardian and a teacher. Additionally, literature suggests that children with encopresis should be assessed for sexual abuse, as encopresis occurs with significantly greater frequency among children with a known history of sexual abuse.
Children consuming a diet low in fiber and consisting of very little fruits and vegetables can increase your child’s likelihood of encopresis. Prepackaged foods, high-sugar foods and fried foods may act as a primary cause or antecedent to your child’s incontinence. Depending on where the incontinence occurs, there may be environmental stressor or factors associated with the child’s behavior. For example, a child may not soil their pants at school, but may exhibit these behaviors upon returning home. This indicates that some extraneous factors in the home are apparent contributing to the unwanted behavior.
Children may hold their bowels too long that it causes their fecal matter to become impacted. There may be psychological (i.e., stress, anxiety, avoidance) or physical (pain, uncomfortable feelings, cramps) that cause the child to hold in their fecal matter. Doctors may prescribe a gentle laxative to assist in making the elimination process easier.
Children with encopresis have been described to fit in one of three categories, manipulative soilers, stress-induced incontinence, or retentive encopresis based on chronic constipation. Few studies have been conducted examining treatment protocols for manipulative soilers, otherwise those known to manipulate their environment. However, studies suggest family counseling incorporating parent training and behavioral modification (e.g., positive reinforcement for defecating in the toilet) are the most promising treatments for encopresis in children.
For the treatment of stress-induced incontinence, supportive psychotherapy – focusing on effective coping skills, stress reduction, and anxiety reduction – and medication (i.e., antidepressant or anti-anxiety medication and anti-diarrhea medication) have been shown to be effective in relieving encopresis symptoms. Also, systematic desensitization, hypnosis, relaxation training, and assertiveness training have been shown in smaller studies to be helpful among children with encopresis.
For treatment of retentive encopresis, treatment management includes standard medical practice, behavior therapy, or combined treatment. Standard medical treatment entails a medication of an enema and/or laxative followed by the oral consumption of 1 to 3 tablespoons of mineral oil twice a day for three months. It is reported that 80% of all children are relieved of symptoms when this treatment is utilized consistently; however, when this regimen stops, relapse is likely to occur. Other studies have reported that this treatment is unsuccessful with children who have a chronic history of behavioral difficulties.
With regards to behavior therapy, a number of reports have documented positive effects of behavior therapy for the treatment of encopresis. In a combined treatment study, nearly 100% success rate was reported with the standard medical procedure incorporating laxatives with behavioral techniques, such as positive reinforcement for defecating in the toilet and mild punishment for soiling underclothes. It is important that parents and caretakers understand that they should never scream or scold their child for defecating in their underpants, as this may actually increase the risk of future episodes. Rather, provide no reaction to the unwanted behavior and extremely positive praise to good defecating behaviors.
Additionally, other studies using similar methodology with the implementation of diet management (i.e., increasing fiber and decreasing dairy) showed significantly positive treatment outcomes for encopresis in children. For children with psychological encopresis, the combination of medical, behavioral, and nutrition management is widely endorsed as the best treatment for this condition.
- Provide a diet full of fiber. Fiber is a natural laxative and will help your child go to bathroom easier.
- Schedule toilet time. Encourage your child to have toilet time approximately 30 minutes after each meal with an attended goal of producing a bowel movement. Give positive praise often, even when the child does not produce a bowel movement.
- Encourage exercise. Exercise stimulates the bowels and can relieve impacted bowels.
- Provide plenty of water. Water hydrates the bowels and gets the colon and intestines moving.
- Limit dairy and cheese. Dairy and cheese can constipate you child and exacerbate their condition.
- Place a small stool or bench in front of the toilet. This may help your child move in different positions when trying to relieve his self.
- Be consistent. Try sticking to these tips for 2 to 3 months in order to see improvement. The relapse rate for encopresis in children is extremely high, so being consistent is absolutely paramount.