Encopresis

What is encopresis?

Encopresis is sometimes referred to as fecal incontinence or soiling. It is a common condition in children, especially toddlers, but it is not discussed often enough.

Encopresis is defined as the repeated passing of stool (voluntarily or involuntarily) in inappropriate places — where stool is not meant to be passed — occurring at least once a month for a period of three months, in children over the age of four years.

The statement above is the formal definition of encopresis. However, in real life, things are a little more complicated than that.

In practice, the problem may sometimes be noticed earlier in childhood, shortly after toilet training. It can present as the child holding in their stool for several days or passing small quantities of stool multiple times a day.

A more practical definition of encopresis would be: the refusal to pass stool in the toilet and repeated soiling.

Rare episodes of soiling following the use of laxatives or other stool-triggering medications or actions are, of course, not classified as encopresis.

What are the causes of encopresis in children?

When the condition first begins to develop, the child often experiences a physiological difficulty in passing stool, usually due to constipation. The pain associated with passing hard stool causes the child to begin avoiding the toilet. As a result, they develop a habit of ‘holding in’ their stool, which then becomes even harder and more difficult to pass. This creates a recurring cycle — the same one discussed in the chapter on constipation.

The child experiences pain when using the toilet, so they avoid it. When they eventually try again, the pain returns, reinforcing the avoidance. And so the cycle continues.

After a prolonged period of constipation and stool retention, the rectal muscle tone may weaken. This can lead to reduced sensation around the anus and a diminished contraction reflex, eventually causing stool to leak into the child’s underwear — especially when they are distracted, such as while playing.

As the condition progresses, emotional difficulties often arise, further complicating the disorder, while the child continues to develop abnormal stooling behaviors.

What are the different types of encopresis and what are their causes?

Medical literature describes two main types of encopresis: retentive and non-retentive.

Retentive encopresis: This form of encopresis is associated with constipation and involves the unintentional leakage of stool. Like severe constipation, it is characterized by infrequent bowel movements (although some parents may mistakenly think their child has diarrhea, not realizing the child is actually soiling multiple times a day), fecal incontinence (soiling), stool-holding behaviors, hard and painful stools, and retention of a large amount of stool in the rectum and large intestine. Treatment involves the use of stool softeners in combination with emotional and behavioral therapy.

Non-retentive encopresis: In this form, there are no signs of constipation. It is defined by episodes of soiling that occur more than once a week for four consecutive weeks, or by passing stool in inappropriate places after the child has been toilet trained. For non-retentive encopresis, stool softeners are not recommended; instead, the focus should be on emotional and behavioral therapy.

Do signs of encopresis require a consult with a physician prior to beginning emotional-behavioural therapy?

Absolutely, yes.

While a child may ultimately benefit from emotional-behavioural therapy regardless of a medical consult—especially as part of a holistic approach to managing the disorder—it is highly recommended to consult a physician first. This allows for the exclusion of anatomical abnormalities or other organic medical causes of constipation.

Additionally, some of these children may present with comorbidities such as abdominal pain, reduced appetite and growth, or urinary retention that may lead to enuresis, all of which can cause significant distress to both the child and their parents. Recurrent urinary tract infections, particularly common in girls, may also occur.

The physician’s role extends beyond ruling out organic causes. Physicians also play a crucial part in guiding parents toward behavioural therapy and raising awareness about the various treatment options available, even for younger children. Furthermore, physicians are instrumental in encouraging parents to adopt an assertive treatment approach to constipation, when necessary—as covered below and in the chapter on constipation.

How does a child who is suffering from encopresis normally act?

Please keep in mind that the behavioural signs mentioned below are not observed in all children with encopresis, but they are present in a large percentage of cases. The purpose of listing these signs is to provide reassurance—to help you understand that you and your child are not alone. These behavioural patterns are well known, common, and relatively manageable with the right support.

Children with encopresis often try to hold in their stool. You may observe them crossing their legs, shifting their bodies, bending, or twisting in an effort to resist the urge. This behaviour can persist for hours or even days. Sometimes, a child’s face may appear tense or turn red due to the strain of holding in stool. Some children retreat to a specific corner to defecate, or they may try to hide entirely.

Stool may leak out when the child is distracted—while playing, for instance. The child might explain this by saying they didn’t want to miss the game.

After soiling, some children deny passing stool and refuse to clean themselves. They may seem emotionally detached from the event, as if they are in denial or unfazed. Others may resist cooperating during clean-up. However, it’s important to recognize that these children are often sensitive and intelligent—and very much affected by the situation.

There are other behavioural tendencies often observed in children with encopresis. These may include stubbornness, a strong need for control, difficulty coping with challenges, fear of new experiences, struggles with delaying gratification, and attention-seeking behaviour.

Some children refuse to use the toilet altogether. Others may sit on the toilet but then cross their legs to prevent passing stool. Some request privacy while using the toilet, while others are anxious and ask a parent to stay nearby. Anxiety and rigidity are common in both scenarios.

How does the condition affect the child and their family members?

Encopresis causes significant distress—both physical and emotional—for the child and their family. This distress stems from reduced quality of life, limitations in spontaneous daily activities, and the emotional toll on both the parents and the child. Parents often struggle to understand why a basic, natural function is so difficult for their child, which can lead to frustration and harsh reactions.

The condition deeply impacts the child emotionally. It undermines their self-esteem, leaving them feeling out of control in a situation where independence is expected. They may be teased or humiliated by peers. Many feel ashamed and worry that they are disappointing their parents. They may see themselves as different or excluded from other children their age.

Children with encopresis often sense that those around them—especially their parents or caregivers—are upset, and they are keenly aware of the fluctuating reactions they receive. These unpredictable shifts from tolerance to impatience can create a sense of emotional instability, confusion, and fear, as the child never knows what response to expect.

Ultimately, many of these children experience a deep sense of loneliness. They feel misunderstood by those closest to them and pressured to perform a task they simply cannot manage. Watching other children carry out this task effortlessly only amplifies their feelings of inadequacy.

How are the parents of children with encopresis affected by the condition?

Most of the parents I encounter at the clinic are in a state of significant distress and are often desperate for help. The condition causes many of them to panic and feel as though they have lost control over their lives.

An important aspect of therapy is helping parents regulate their reactions to the situation, which requires knowledge, guidance, and support.

Their concerns and frustration are completely understandable—caring for a child with encopresis can be extremely challenging. However, expressing anger or scolding the child tends to worsen the situation and may provoke extreme reactions from the child.

The therapy I provide includes a behavioural profile analysis for the child and emotional support for the parents. Parental therapy is conducted without the child present, as there is no need to involve a young child in this part of the process (beyond any therapy required to treat the constipation itself).

When encopresis presents during adolescence, it may be appropriate to involve the child in counselling. However, parental support and guidance remain essential.

Does the educational institution that the child attends need to be made aware of the child’s condition?

Yes. It is important that the school or kindergarten is informed of the child’s condition and the related challenges. This can help prevent difficult or embarrassing situations during the school day.

It is advisable to speak with a compassionate teacher who can offer support when incidents occur. Ensuring the child has easy access to the restroom is crucial. The teacher and child can agree on a discreet way for the child to signal when they need to use the toilet, so they don’t lose time waiting for permission.

Once parents or caregivers communicate openly with the educational team about the child’s needs, most schools or kindergartens respond with understanding and support.

What are the management principles of encopresis in children?

There are three main components to managing encopresis, and each is closely connected to the others:

• Treating constipation
• Behavioural therapy
• Emotional therapy

I will elaborate on each of these below.

How is the constipation itself treated?

Treatment for constipation includes:

• Regular physical activity and adequate fluid intake
• Pharmacological treatment, as discussed in the post about constipation. This treatment helps re-train the child to understand that passing stool doesn’t have to be painful. Polyethylene glycol or one of its derivatives is commonly used for this purpose.

It is essential to soften the stool so that the child can empty their bowels completely and without pain.

As emphasized throughout the constipation chapter, a common issue is that parents tend to reduce the dosage or stop treatment too early—before the child has established healthy stooling habits. This is often due to concern about giving their child a laxative long-term. However, this concern is unfounded. If the child’s intestines and rectum remain filled with stool, the psychological and behavioural aspects of encopresis will not improve.

What does the behavioural therapy for encopresis in children entail?

Behavioural therapy involves teaching the child a sequence of behaviours they were expected to develop naturally. The failure to acquire this behavioural chain is usually due to a combination of emotional and physiological factors. The behaviour chain includes:

• Recognizing the need to pass stool
• Pausing any pleasurable or ongoing activity
• Overcoming resistance and going to the toilet
• Passing stool in the toilet

This chain is taught in a way tailored to meet the specific needs of the child and their family.

Positive reinforcement plays a key role in this therapy. Praise and encouragement should be given whenever the child overcomes an obstacle, cooperates with the treatment, demonstrates flexibility, or shows growing self-confidence. It’s important to reward any behavioural improvements—not just full success. Examples include stopping an activity to go to the toilet or simply expressing the need to go.

As the child begins to succeed and show behavioural progress, positive feedback helps reinforce these changes. Over time, the child learns a new behavioural pattern and gains confidence in their ability to improve.

What does emotional therapy for encopresis in children entail?

It’s important to distinguish between behavioural therapy (discussed above) and the emotional therapy that both the child and their family need.

It’s clear that children suffering from encopresis are dealing with complex emotional challenges, and that the condition is difficult for parents as well. Parental reactions often fluctuate—driven by stress, frustration, or concern—but empathy and emotional tolerance are essential.

Emotional therapy focuses on addressing emotional difficulties and rebuilding healthy family dynamics. It includes an analysis of both behavioural and emotional patterns, and support for emotional challenges that existed prior to the encopresis, as well as those that continue to fuel it.

The therapy also involves raising parental awareness of the challenges their child is facing. One key issue with children suffering from encopresis is their tendency to internalize emotions. These children are often very sensitive and emotionally intense—it’s crucial to provide them with a safe outlet for expression.

Helping the child learn to recognize and express their emotions outwardly is a core part of therapy. Parents are taught how to communicate empathetically and how to create an open, accepting atmosphere for discussion. They also learn how to apply behavioural reinforcement effectively to build the child’s confidence, encourage cooperation, reduce shame and disappointment, and teach flexibility.

In addition, parents are guided on how to create quality one-on-one time with their child, which helps reduce the child’s need for constant attention.

How should parents react when they notice that their child is soiling, and what kind of reactions should be avoided?

When your child soils, it’s important not to give the incident unnecessary attention. Avoid angry or emotional reactions, and don’t attempt to comfort them in that moment.

Calmly take your child to wash up, and use neutral, non-shaming language. For example, avoid phrases like “you’re dirty.” Instead, say something like: “It must be uncomfortable to be in dirty underwear—let’s go wash up and get changed.” And that’s it.

At the same time, seek professional help and begin appropriate treatment.

Therapy includes parental guidance on how to manage the condition effectively. The belief is that parents should lead the child’s treatment and learn how to communicate in ways that meet the child’s emotional and behavioural needs.

This therapy is focused and practical—and can be learned at any stage of parenthood.

In summary, this is a complex condition that combines medical, behavioural, and emotional elements. Recognizing it is the first and most important step. Once that happens, the path to resolution becomes clearer and more manageable.

With the support of an experienced therapist and a pediatrician familiar with treating constipation, full recovery is possible—and the condition can eventually become just a memory.

Get the help you need, from the right professionals, at the right time—and good luck, my friends!