This is a very important chapter discussing quite a tough topic in pediatrics. Prior to reading it I think reading and understanding the chapter about constipation on this website is a must. You can find it at the link here.

The following post was written by Tammy Heymann Azoulay, a clinical behavioural analyst and family counsellor that has helped lots of parents manage and deal with this difficult condition. You can read more about Tammy here.

What is encopresis?

Encopresis is sometimes referred to as fecal incontinence or soiling. It is a common condition in children, especially infants, but it is not discussed enough.
Encopresis is the repeated passing of stool (voluntarily or involuntarily), in inappropriate places, where stool is not meant to be passed, at least once a month, for a period of 3 months, in children over the age of 4 years.
The statement above is the proper definition of encopresis. However, in real life things are a little bit more complicated than that.
In practice, the problem is sometimes noted earlier in childhood, shortly following toilet training. It can present with the child holding in their poop for several days or passing small quantities of stool, several times a day.
A more accurate definition of encopresis would be – the refusal to pass stool in the toilet and repeated soiling.
Rare episodes of soiling, following use of laxatives or any other stool-triggering drugs/actions are obviously not referred to as encopresis.

What are the causes of encopresis in children?

When the condition first starts developing in a child, we will notice that the child experiences an organic (physiological) difficulty when attempting to pass stool. This occurs as a result of constipation, which causes the child to avoid passing stool because of the pain they experience when doing so. The child then develops a habit of ‘holding in their poop’ and their stool slowly becomes even harder. This leads to a recurring cycle of events; the same one you learned about in the topic about constipation. The child finds passing stool painful, so they avoid the toilet. When they go to the toilet, they experience pain again. And it goes on.
After a lengthy period of constipation and holding in feces, the rectal muscle tone weakens, and this can lead to reduced sensation around the anus and a relative loss of the contraction reflex. This could then lead to stool leaking out into the child’s underwear, especially when the child is distracted – for example while playing a game that may distract him/her from remembering to hold in their poop.
As this condition develops, emotional difficulties arise as well, and they worsen the disorder all while the child continues to adopt abnormal patterns of stooling behaviour.

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

The medical books talk about two types of encopresis: retentive and non-retentive encopresis.

Retentive encopresis: this form of encopresis is accompanied by constipation and the simple leakage of stool. Similarly to severe constipation, it is characterised by a lower frequency of stool passing (even though some parents come into the clinic thinking their child has diarrhea and do not realize that their child is in reality soiling several times a day), fecal incontinence (soiling), maneuvers to hold the stool in, hard and painful stools and retention of a large quantity of stool in the rectum and large intestines. This form of encopresis requires treatment with stool softeners as well as emotional-behavioural therapy.

Non-retentive encopresis: in this form of encopresis there are no signs or evidence of constipation. It is defined as episodes of soiling occurring more than once a week for 4 consecutive weeks or the passing of stool in inappropriate places even after the child has been toilet trained. For this type of encopresis, stool softeners are not advised and it is best to focus on providing the child with emotional-behavioural therapy.

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

Absolutely yes.
It is possible that the child will end up needing emotional-behavioural therapy regardless of the consult, to provide the child and family with a holistic approach to the disorder. Nonetheless, seeing a physician is highly recommended so that anatomical defects or other organic medical causes of constipation can be ruled out.
In addition, some of these children may also have comorbidities such as abdominal pain, decreased appetite and growth and urinary retention that may eventually lead to enuresis, which cause the child and the parents’ great distress. Sometimes, these children suffer from recurrent urinary tract infections. This is especially common in girls.
The physician’s role is not restricted to ruling out organic causes of constipation and encopresis but also includes encouraging the parents to pursue behavioural therapy and raising awareness about the availability of different management options even for the younger patients. Furthermore, physicians play a major role in encouraging the parents to assume aggressive treatment for constipation, if need be, as you will see below and as you’ve probably already learned in the chapter about constipation.

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

Keep in mind that the examples of behavioural signs that I will be mentioning below are not present in all children with encopresis but are seen in a large percentage of them. The purpose of sharing this with you is to provide you with some relief and to help you realize that you and your child are not alone. These patterns of behaviour are well known, common, and relatively easy to treat.

Children tend to hold in their stool and so you will often see them crossing their legs, moving around and bending and twisting to aid with this. This type of behaviour can last from hours to days. Sometimes you’ll find the child’s face somewhat “freezing” and turning red, due to the effort they need to put into holding the stool in. Sometimes they will repeatedly go to the same corner to pass their stool, or they may even try to hide.
The stool may also “leak” when the child is playing a game, while they are distracted. The child may excuse themselves by claiming they did not want to miss out on the game.
Following soiling, some children refuse to wash up, claiming they did not pass stool. They may seem disconnected from the unpleasant event (they are in denial) and it may even feel almost as though they are not bothered by it. Some will refuse to cooperate with the washing up process. It is obvious to all of us though that these children to get bothered by the situation, as they are usually very sensitive and smart children.
There are additional behavioural trends that may be seen in a lot of the children who suffer from encopresis. Some of these include stubbornness, a need to feel in control, difficulties in overcoming obstacles, a fear of trying new things, difficulties in delaying gratification and attention-seeking behaviour.
Some of these children will refuse to go to the toilet, others will agree to go but once seated on the toilet seat will cross their legs to avoid passing stool. Some children will request their privacy while attempting to pass stool, while others fear being left alone and ask one of their parents to remain with them. Anxiety and rigidity are seen in both cases.

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

This condition causes the child and their family a lot of distress, both physical and mental. This distress is due to a reduction in quality of life, difficulties with undertaking spontaneous daily activities, difficulties for the parents dealing with it and difficulties due to the child’s feelings of embarrassment. For the parents, it is hard to comprehend why such a basic and natural task is so difficult for their child. That is why many parents panic and react in a very harsh manner.

The condition has a wide emotional impact on the child. Firstly, it affects their self-esteem. The child feels a loss of control over their life, and this is a difficult thing for a young child to accept, especially when what is expected of them is the exact opposite. Other children often say hurtful and humiliating words to them. The child may feel disappointed of themselves and feel that they are disappointing their parents. The child may also feel like an outcast among children his/her age. These children often get the feeling that the people surrounding them are upset with them and are aware that their parents/caretakers’ reactions frequently shift from tolerance to impatience. These shifting reactions cause the child to feel instability, confusion and fear as they do not know what kind of reaction to anticipate from their caretaker. Furthermore, the children experience loneliness. The people closest to them do not understand them and expect them to fulfil a task that they are incapable of performing. They find it difficult to perform a simple task that other children seem to carry out without any problems.

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

Most of the parents that I encounter at the clinic are in a state of great distress and they are often also desperate for help. The condition causes these parents to panic and feel as though they have lost all control over their lives.
An important aspect of the therapy is to help regulate the parents’ reaction to the situation, and therefore knowledge, guidance and support is necessary.
Their concerns and anger are understandable; dealing with a child with encopresis is very difficult. However, being angry with the child and scolding them only makes things worse and causes the child to react in an extreme manner.
The therapy that I provide includes behavioural profile analysis for the child and emotional therapy for the parents. The parents receive this therapy alone, and not in the presence of the child, as there is no need to involve the young child in the process (apart from providing the child with the therapy required for the constipation itself).

When encopresis presents in adolescence, it is possible to involve the child parent counselling is still necessary.

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

Yes. It is best if the institution is made aware of the condition and the difficulties that accompany it. This helps avoid situations and mishaps at kindergarten or school. Discussing the condition with a caring teacher that can help with episodes when they occur, is advised. Easy access to the toilets at kindergarten or school is also important. The teacher and student can agree on a way to communicate discretely when the child feels the urge to go to the toilet, so that the child does not waste any time waiting for the teacher’s approval.
After parents or the caretaker have shared the difficulties of the condition with the educational team, most institutions tend to keep a positive and helpful outlook to the matter.

What are the management principles of encopresis in children?

There are 3 main components to management and they are greatly dependent on one another:
# Treating constipation
# Behavioural therapy
# Emotional therapy
I will elaborate on each of these below.

How is the constipation itself treated?

The treatment for constipation includes:
# Exercising regularly and drinking plenty of fluids
# Pharmacological treatment for constipation, as discussed in the post about constipation. With the help of this treatment, we can re-teach the child that passing stool does not have to be a painful experience. We often use polyethylene glycol or one of its derivatives for this.
Keep in mind that stool softening is important so that the child can fully empty their bowels without experiencing any pain while doing so.
As mentioned several times in the chapter about constipation, one of the more common problems with constipation is that parents tend to reduce the dose or cut the course of the treatment short, before the child has fully adopted the correct stooling patterns because they feel that they are giving their child a laxative and that it may be harmful to them. This is not true. If the child’s intestines and rectum are full of stool, the psychological and behavioural aspects of the disorder will not resolve.

What does the behavioural therapy for encopresis in children entail?

The behavioural therapy includes instilling a behaviour chain in the child, that they were supposed to have acquired naturally. The failure of this behaviour chain to develop naturally is usually a result of both emotional and physiological factors. The behaviour chain includes:
# Identifying the need to pass stool
# Pausing any pleasurable activity or any other sort of activity
# Overcoming the difficulty and going to the toilet
# Passing stool in the toilet
The child is taught this behaviour chain in a way that is tailored to meet both the child and family’s needs.
Positive feedback plays a major role in the therapy. Positive feedback should be expressed when the child successfully overcomes obstacles, cooperates with the management techniques, conveys flexibility and the ability to trust him/herself. It should also be expressed when the child demonstrates any sign of improvement in their behaviour and not only once they are fully successful in passing stool in the toilet. Any behavioural signs of improvement should be rewarded. For example, stopping an activity or game and going to the toilet, or stating the need to go to the toilet and agreeing to go.
When the child experiences success and improvement in their behaviour, positive feedback helps bring about the recurrence of this success, and gradually the child learns a new pattern of behaviour and realizes that they have the capacity to improve.

What does emotional therapy for encopresis in children entail?

Note the difference between behavioural therapy, mentioned above, and emotional therapy that the child and family need.
It is obvious to all of us that a child who suffers from this condition has a lot going on, and that the condition is very difficult to deal with for the parents. The parents’ reactions can shift quickly, and this stems from their desperation and concern. However, the parents’ empathy and tolerance to the situation are absolutely necessary.
The emotional therapy focuses mainly on emotional difficulties and on restoring the inter-familial relationships. It includes behaviour and emotional profile-analysis and providing support for the emotional difficulties that preceded the altered behaviour and those that continue to feed it.
Additionally, the therapy places an emphasis on raising awareness about the difficulties that the child has to overcome among his/her parents.
One of the main challenges with these children is the way they hold onto their emotions. Most of the children who suffer from encopresis are very sensitive, their emotional world is raging and it is important to provide them with an outlet to vent. The process through which the child learns to recognize their own emotions and express them openly to the external environment is important. Throughout the therapy, the parents learn how to converse empathetically with their child and talk to them openly. The parents also learn how to provide their child with an open and accepting atmosphere for discussion. Learning behavioural reinforcement is very important for the development of the child’s sense of competence, encouraging their collaboration, motivating them to overcome obstacles, teaching them flexibility and reducing their feelings of disappointment and shame. Furthermore, parents learn how to initiate quality time with their child so that the child’s need for constant attention decreases.

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

It is important not to give the child attention when they pass stool in places other than the toilet. Make sure that your reaction is anger-free and that you do not attempt to console them in any way when it happens. Take your child to wash up and do not use words such as “you’re dirty”. Instead, try saying “it must be so uncomfortable to be in dirty underwear, let’s go wash up and get changed”. And that’s it.
At the same time, seek help and start adequate treatment.
The therapy entails parental guidance on how to manage the problem, because it is strongly believed that the child’s treatment should be handled by the parents and that they need to learn how to communicate properly with them and provide them with the best care for their needs.
The treatment is focused and practical, and parents can learn it at any stage in parenthood.

In summary, this is a complex medical-behavioural-emotional condition. First and foremost, one must recognize its existence, and once that is done, the route to resolution becomes simpler and shorter.
Professional help by a caregiver that is well experienced, as well as a pediatrician that knows how to manage constipation, can bring about complete resolution and slowly turn the condition into a memory from the past.
Get the help you need, from the right healthcare professionals, at the right time to treat this complex condition.
And good luck my friends!

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