My child is way past toilet training, but he still soils his underwear. What should I do?
Encopresis is one of the more frustrating disorders of middle childhood. It is the passing of stools into the underwear or pajamas, far past the time of normal toilet training. Encopresis affects about 1.5 percent of young school children and can create tremendous anxiety and embarrassment for children and their families.
Encopresis is not a disease but rather a symptom of a complex relationship between the body and psychological/environmental stresses. Boys with encopresis outnumber girls by a ratio of six to one, although the reasons for this greater prevalence among males is not known. The condition is not related to social class, family size, the child’s position in the family or the age of the parents.
Doctors divide cases of encopresis into two categories: primary and secondary. Children with the primary disorder have had continuous soiling throughout their lives, without any period in which they were successfully toilet trained. By contrast, children with the secondary form may develop this condition after they have been toilet trained, such as upon entering school or encountering other experiences that might be stressful.
A frustrating condition
Children, parents, grandparents, teachers and friends alike are often baffled by this problem. Adults sometimes assume that the child is soiling himself on purpose. While this may not be the case, children can play an active role in managing the processes involved in this disorder.
The physical aspects of encopresis
When encopresis occurs, it begins with stool retention in the colon. Many of these youngsters simply may not respond to the urge to defecate and thus withhold their stools. As the intestinal walls and the nerves within them stretch, nerve sensations in the area diminish. Also, the intestines progressively lose their ability to contract and squeeze the stools out of the body. Therefore, these children find it increasingly difficult to have a normal bowel movement. Most of these children are chronically constipated.
With time, these retained stools become harder, larger and much more difficult to pass. Bowel movements then can be painful, which further discourages these children from passing the stools.
Eventually, the sphincters (the muscular valves that normally keep stools inside the rectum) are no longer able to hold back all the stool. Large, hard feces may be retained in the colon (large intestine) and rectum, but liquid stool can begin to seep around this impacted mass, passing through the anus and staining the underwear. At other times, semiformed or partial bowel movements may pass into the underwear, and because of the decreased sensation, the child may not be aware of it.
Some youngsters are predisposed from birth to early colonic inertia – that is, a tendency toward constipation because their intestinal tracts lack full mobility. Early in life these children might have experienced constipation that required dietary and medical management.
Some children develop constipation and encopresis because of unsuccessful toilet training as toddlers. They may have fought the toilet training process, been pushed too fast, or were punished for having accidents. Struggling with their parents for control, they may have voluntarily withheld their stools, straining to hold them as long as they could. Some children may actually have had a fear of the toilet, even thinking that they themselves might be flushed away.
A number of other factors can also contribute to the eventual development of encopresis. Sometimes children may have pain when they have a bowel movement due to an infection or a tear near their rectum. Emotional causes can include limited access to a toilet or shyness over its use (at school, for example), or stressful life events (marital discord between parents, moves to a new neighborhood, family physical or mental illnesses or new siblings). While most children with encopresis are also constipated, some are not. These children may refuse to use the toilet and simply have normal bowel movements in their underwear or other inappropriate places. In general, these children are demonstrating their attempts to control some difficult aspects of their lives. Professional help is advisable for these children and their families.
Many parents are astonished that their child with encopresis may not even be conscious of the odor emanating from the stool in his pants. When this odor is constant, the smelling centers of the brain may become accustomed to it, and thus the child actually is no longer aware of it. As a result, these youngsters often are surprised when a parent or someone else tells them that they have an odor. While the youngster himself may not be bothered by the smell, the people around him may not be sympathetic to his problem.
Exasperated parents often place great pressure on their child to change this behavior – something the youngster may be incapable of without help from a pediatrician. While family members may have ideas on how to solve the problem, their efforts generally will fail when they do not understand the physiological mechanisms at work.
Encopresis can lead to a struggle within the family. As parents and siblings become increasingly frustrated and angry, family activities may be curtailed or the child with encopresis may be ostracized from them. By this stage, the problem often has become a family preoccupation.
As the child and family fruitlessly battle over the child’s bowel control, the conflict may extend to other areas of the child’s life. His schoolwork may suffer; his responsibilities and chores around the home may be ignored. He may also become angry, withdrawn, anxious, and depressed, often as a result of being teased and feeling humiliated.
Management of encopresis
Encopresis is a chronic, complex – but solvable – problem. However, the longer it exists, the more difficult it is to treat. The child should be taught how the bowel works, and that he can strengthen the muscles and nerves that control bowel function. Parents should not blame the child and make him feel guilty, since that contributes to lower self-esteem and makes him feel less competent to solve the problem.
Parents often use a behavior modification or reward system that encourages the child’s proper toilet habits. He might receive a star or sticker on a chart for each day he goes without soiling and a special small toy, for example, after a week. This approach works best for a child who truly wishes to solve the problem and is fully cooperative in that effort.
Some youngsters have significant behavioral and emotional difficulties that interfere with the treatment program. Psychological counseling for these children helps them deal with issues like peer conflicts, academic difficulties, and low self-esteem, all of which can contribute to encopresis.
Throughout this treatment process, parents should remind the child that there are other youngsters who have the same problem. In fact, children with the same difficulty probably attend his own school.
Children with encopresis may have occasional relapses and failures during and after treatment; these are actually quite normal, particularly in the early phases. Ultimate success may take months or even years.
One of the most important tasks of parents is to seek early treatment for this problem. Many mothers and fathers feel ashamed and unsupported when their child has encopresis. But parents should not just wait for it to go away. They should consult their doctor and make a persistent effort to solve the problem. If the symptoms are allowed to linger, the child’s self-esteem and social confidence may be damaged even more.
When encopresis is occurring in a school-age child, a physician experienced in encopresis treatment and interested in working with the child and the family should be involved.
The treatment goals will probably be four fold:
- To establish regular bowel habits in the child
- To reduce stool retention
- To restore normal physiological control over bowel function
- To defuse conflicts and reduce concerns within the family brought on by the child’s symptoms
To accomplish these goals, attention will be focused not only on the physical basis of encopresis but also on its behavioral and psychological components and consequences.
In the initial phase of medical care, the intestinal tract often has to be cleansed with medications. For the first week or two the child may need enemas, strong laxatives or suppositories to empty the intestinal tract so it can shrink to a more normal size.
The maintenance phase of management involves scheduling regular times to use the toilet in conjunction with daily laxatives like mineral oil or milk of magnesia. Proper diet is important, too, with sufficient fluids and high-fiber foods. These steps will keep the stool soft and prevent constipation. When improperly supervised, these interventions have potential dangers for the health of the child and so should be done only under the supervision of the child’s physician. The maintenance phase will usually last two to three months or longer.