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Accommodating Hyperactivity in Children with ADHD

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Posted on by Leonardo Rocker (Quirky Kid Staff)

Accommodating Hyperactivity in Children with ADHD

ADHD which affects approximately 7.2% of children worldwide (Thomas, 2015) presents as either the hyperactive-impulsive, inattentive or combined subtype (Willcutt, 2012). It is often first suspected by classroom teachers who witness the symptoms of hyperactivity and inattention. An interesting new study suggests that students with ADHD are more attentive when allowed to fidget.

While behaviour modification efforts, especially in the classroom setting, are often aimed at reducing both hyperactivity and inattention, new research published in Child Neuropsychology suggests that fidgeting may actually help children with ADHD increase focus and exercise better mental control, contributing directly to an increase in performance on cognitive tasks (Hartanto, 2015).

Professor Julie Schweitzer of the Psychiatry and Behavioural Sciences department at the MIND Institute at the University of California, spearheaded the study of 26 children with confirmed diagnoses of ADHD, which saw the leg movements of each child recorded by ankle monitors that each child was wearing during a series of computerised activities testing both cognition and attention.  The results of the study confirmed that incidents of increased fidgeting directly correlated with a high level of accuracy in test performance.  Conversely, the more still the children were during the test the more poorly they performed on the tests of cognition and attention.  According to Schweitzer these results suggest that constant movement probably increases mental arousal for children with ADHD, much as stimulant drugs do.

The practical application of the study’s results seems clear to Schweitzer. Adults should encourage children with ADHD to fidget rather than correct them for it, especially during activities that require a high level of focus.

While Schweitzer’s research supports her conclusions, other scholars suggest that simply making accommodations for ADHD students to fidget misses the mark entirely, and that the real solution for children with ADHD when trying to focus in school is one that would support the student population as a whole (Tomporowski, 2011).  That is, all people benefit from the opportunity to move around regularly throughout the day, whether diagnosed with ADHD or not, and incorporating more physical activity into the school day might alleviate the need for fidget-friendly classrooms in the first place. Harvard-trained educator and McLean Hospital alumna Nina Fiore emphasises that, “Regular movement has been shown to increase focus and retention in children and adults of all ages…and diagnoses would be lessened if more movement was incorporated into every aspect of school.”

Schweitzer and Fiore are in agreement about one thing, and that is that all children can perform better when they are provided with an outlet for physical activity.  It may be that in the future more schools around the world will incorporate a degree of movement into the daily schedule high enough to alleviate the need for classroom-friendly fidget solutions.  In the interim, however, Schweitzer offers some practical solutions that are designed to avoid distracting other students in the classroom.  Her ideas include:

  • allowing children to stand and stretch as needed, attaching elastic bands beneath children’s desks so that they can pull and play with them in a way that shouldn’t bother other children, or using yoga balls as chairs, so the children can bounce.
  • The yoga ball seat approach in particular, has gained popularity among educators, as evidenced by three American elementary schools that have replaced classroom chairs with yoga balls entirely.  One such educator, Robbi Giuliano, who teaches 10-year-olds in West Chester, Pennsylvania, describes the switch as one of the best decisions she has ever made, saying, “I have more attentive children.  I’m able to get a lot done with them because they’re sitting on yoga balls.”

Many other opportunities exist for physical activities in the classroom, particularly ones that are neither disruptive nor stigmatising, and they can be used in school settings to help children perform cognitively demanding tasks.

To talk more about this, or anything else, please contact us.  If you are considering an assessment for your child, please review our assessment pages.

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References

Hartanto, T. A., Krafft, C. E., Iosif, A. M., & Schweitzer, J. B. (2015). A trial-by-trial analysis reveals more intense physical activity is associated with better cognitive control performance in attention-deficit/hyperactivity disorder. Child Neuropsychology, (ahead-of-print), 1-9.

Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P.  (2015). Prevalence of attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Pediatrics, 135(4), 994-1001. 

Tomporowski, P. D., Lambourne, K., & Okumura, M. S. (2011). Physical activity interventions and children’s mental function: an introduction and overview. Preventive Medicine, 52, S3-S9.

Willcutt, E. G., Nigg, J. T., Pennington, B. F., Solanto, M. V., Rohde, L. A., Tannock, R., … Lahey, B. B. (2012). Validity of DSM-IV attention–deficit/hyperactivity disorder symptom dimensions and subtypes. Journal of Abnormal Psychology, 121(4), 991–1010. 

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Managing Interruptions

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Posted on by Dr. Kimberley O'Brien

Helping Parents to Manage Children Interruptions

Engaging in adult conversation, for many parents, is a rare opportunity. With busy schedules, tag-team parenting and children in need of attention, brief connections with other parents and even your own partner, are often few and far between. Given the infrequency of such events, it is not surprising most parents are angered when children interrupt…on purpose…all the time!

Young children and patience

For children under the age of 8 years, the importance of patience is a difficult skill to acquire. Young children are impulsive by nature and being told to “wait a minute” is likely to be lost when parents are engaged in a frantic flow of words. Managing interruptions in a calm manner, requires planning and practice, to avoid a potentially positive exchange from going pear-shaped.

Helping children manage interruption

Interrupting, may take the form of ‘talking over others’,‘creating a loud distraction’ or physically pulling on a person to gain attention. Let’s face it, many adults do all these things to toddlers to encourage them to move on from one activity to the next, so it’s not surprising children try the same antics as they mature. Interestingly, however, the majority of school-aged students resist the urge to interrupt their teacher, while at home most children have no qualms about interrupting their parents. Based on stories generously shared by clients in the clinic, I know interruptions tends to peak when one parent returns home from work and everybody wants to talk at once. Unfortunately, children tend to bare the brunt of the blame, when parents are tired and decent communication seems like a thing of the past.

One of the best ways to help children aged 2-6 years learn to avoid “interrupting” is to give them some tools to manage it.

  • Firstly, set the scene. Help your child imagine where the interruption may take place and then role play some suggestions. For example, suggest your child holds your hand when they have something to say and squeeze their hand in return, to acknowledge their request. Alternatively, the child’s signal could be to place their hand on the parent’s knee, if the parent is seated, and in response the parent places their hand on top, as a silent gesture of recognition. These techniques are best applied in a social setting, when subtle signs are more easily recognised. Special signals between parent and child strengthen the relationship and far outweigh an angry exchange, eg; “DON’T INTERRUPT!” in the company of friends, which typically terminates the conversation anyway.
  • In the home setting, the whole family may wish to be involved in a role play where interruptions are rife. However, the role play should be conducted on a weekend when there is sufficient time to test out everybody’s ideas. Switching roles, whereby a parent plays the role of child, and vice versa, will help both parties see the situation from a different point of view. Giving the issue of interrupting a solid focus in the presence of all family members, doesn’t need to involve a stern warning. A role play will inject some humour into a situation and laughter will lubricate discussion around a sensitive family issue. Consider pausing mid-role play to ask for suggestions about how to fix the issue. Be open to ideas.
  • There are many ways to create change. Consider having more brief conversations, rather than one long discussion with the same person. Use a timer to set limits on one-to-one adult conversation and graph your child’s improvements in the ‘patience department’.
  • A visual graph on the fridge may be a source of pride for children and a reminder of progress. Imagine the difference when interrupting occurs every 3 minutes as opposed to every 3 seconds. Verbal praise after a successful social interaction should also be part of the equation, both at home and in the community.

Luckily the ‘interrupting phase’ for children is typically short-lived. As children mature and early adolescence emerges, conversations with peers far outweigh any desire to interrupt adult exchanges. Parents are more likely to find themselves interrupting long phone calls between adolescent girls or cutting short late night social exchanges on Skype. In these circumstances, remember the time it took you to teach your children the rules of patience and respect…and remember to employ these social skills in return.

Think: silent signal, recognition in return and a pre-planned time frame to wind up the conversation.QK

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Understanding and Accepting Your Child

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Posted on by Leonardo Rocker (Quirky Kid Staff)

Understanding and Accepting Your Child

Have there ever been times when you have looked at your child and just felt so different from them? Have you ever been left wondering what tree did they did in fact fall from?

Writer, activist and Psychiatrist, Andrew Solomon has recognised the commonality of these feelings amongst parents and families in his book ‘Far From The Tree’ and discusses how negotiating difference within families is a universal phenomenon.

While the diversity and uniqueness of all humans provides the rich tapestry of the world we live in, feeling very different to our own children can be a challenge to embrace and can cause friction in families. Common challenges include negotiating routines and family structures, finding things all family members enjoy doing together and questioning your parenting abilities and capabilities. Often parents at the Clinic stress that it is not the love for their child that is lacking but the ability to accept their child and enjoy their uniqueness that poses the challenge.

Acceptance in parenting can be conceptualised as being able to see and acknowledge the uniqueness in your child, without pressing for this to change, as Andrew Solomon states, it is “finding the light in your child and seeing it there” (Solomon, 2014). This doesn’t mean that we don’t strive to shape our children’s behaviour, educational outcomes, sporting ability etc, but rather, we accept and validate with warmth their unique personality, we love them for being them. Studies consistently tell us that children who feel accepted by their parents have a better more secure relationship with their parents, a heightened sense of family connectedness, higher self esteem and fewer psychosocial challenges, such as anxiety and depression (Ansari & Qureshi, 2013; Dwairy, 2010). The heartening news is that acceptance is something which can be learnt and developed over time. At the Quirky Kid Clinic, we use some practical strategies to facilitate acceptance within families.

Assess your own expectations

One of the biggest blocks to being able to accept your child is holding onto unrealistic expectations of your child and yourself. Some common expectations include “my child should be academic”, “to be successful my child must focus and work hard”, “it is not normal to be so fussy”, “I am a bad parent if I don’t like spending time with my child”.  Statements that include “should”, “must”, “meant”, “not normal”, “bad parent” will invoke stress, anxiety and often anger, and typically do not reflect the true reality of the situation. Most parents can agree that having a happy child that achieves within their capabilities, academically, socially, physically and emotionally, is their hope and dream. Just because your child is not like you doesn’t mean that they are not valuable and certainly doesn’t mean that you have failed in your role as a parent in any way. Replace these statements with more helpful and realistic statements, like “my child may not be academic but they have other skills”, “being successful is finding a happy balance”, “most children can be fussy”, “all people are unique and so is my child” and “I am a normal parent experiencing common thoughts among parents”. Most parents don’t have mini-clones of themselves and most experience the challenges of raising unique children at some stage.

Become a child- scientist

Acceptance is fostered through understanding and knowing. Get to know what makes your child tick, what they love doing, what interests them, who they feel close to, what they want you to be doing with them. A helpful way to elicit this information is to discuss these questions during parallel communication times (ie. when you’re talking but not face to face) such as in the car, taking a walk, playing a game or at bedtime). For younger children, drawing can be helpful. A lovely activity to do together is draw a world and put all the people that are in their world onto the picture (you can write or draw). Using stickers, you can then identify people who love them (heart stickers), people who are good to talk to (dot stickers), people who are good to have fun with (star stickers) and people who help them (triangle stickers) (Lowenstein, 1999). Use this information to develop and strengthen your child’s support network.

Take turns in doing things together that you and your child enjoy and make time in your schedules to have fun together. Make space in your house to cater for your child, whether it be a spot for lego, music, games or special interest books. It can also be helpful to have a family friend whom you can enlist as a support person for your child and who can also take an interest in your child’s life.

Become a mindful parent

Mindful parenting focuses on developing awareness around interactions with your child through focusing your attention on your child’s needs in a particular moment whilst regulating your own emotions (Duncan, Coatsworth, D & Greenberg, M., 2009).  Being in tune with your child is likely to help your child feel accepted and valued.  While mindful parenting sounds difficult to achieve, there are some steps you can take to help develop your skills in this area.

  1. Listen with your full attention: focus on what your child is communicating to you, what words are they using? what facial expressions do they have? look them in the eye, down at their level and show them that you can hear them. Active listening helps parents understand the needs and meaning behind behaviour.
  2. Communicate: reflect back to the child what you hear them saying. Try and not make judgements here, just reflect what you can see and hear. For example, “you are feeling very angry because your brother used your special cup”. This can help your child build awareness of their own behaviours and acknowledge you are listening and hearing them.
  3. Help your child label their emotions: it is important for children to be aware of the emotions they are feeling as it can really help them make conscious choices about how to respond to them. For example, parents may say “ it looks like you are angry because I can see your fists tensing up, your face looking red and you are shouting”.
  4. Demonstrate self regulation and compassion: Pausing before your own reaction and teaching your child to do the same (eg. count to 10 before reacting or blowing out 3 breaths to blow off the anger) can help to limit unplanned and heated arguments or words that can impact negatively on children and parents. Showing empathetic concern towards your child shows them that you love them despite the situation and demonstrates your acceptance despite the behaviour. Following on from this process, behaviour can then be addressed through using calming strategies, timeout and removal of privileges in a calm and planned manner.

Warmth and Praise

Feeling accepted comes from feeling validated as a person. Warmly validating your child on a daily basis can improve relationships, behaviour and family connectedness. Some helpful ways to validate your child include:

  1. making a photo wall of all the things you like about them and what they do. For example, taking photos of them hugging their sister, playing their lego and of family outings can help your child know that you notice and feel happy about special things they do or may be interested in. You can write in captions and put the date on the photos to elicit more meaningful memories of the special time/ activity/ quality.
  2. use plenty of specific praise: tell your child you love them and praise specifically every day. For example, “I loved how you noticed when mummy felt unwell and thought to get her some tissues”. This tells the child exactly what things you have noticed and loved about them.
  3. make a Brag Book (Lowenstein, 1999): at the end of every day, write one praise point in your child’s book that you can read together before bed. Again, make the praise specific. This book can be a concrete reminder to your child that you love and accept them.

References

Ansari, B. & Qureshi, S. (2013). Parental Acceptance and Rejection in Relation with Self Esteem in Adolescents. Interdisciplinary Journal of Contemporary Research in Business, 4 (11), 552-557.

Duncan, L. Coatsworth, J. & Greenberg, M. (2009). A Model of Mindful Parenting: Implications for Parent-Child Relationships and Prevention Research. Clinical Child and Family Psychology Review, 12 (3), 255-70.

Dwairy, M. (2010). Parental Acceptance-Rejection: a Fourth Cross-Cultural Research on Parenting and Psychological Adjustment with Children. Journal of Child and Family Studies, 19 (1), 30-35.

Lowenstein, L. (1999). Creative Interventions for Troubled Children and Youth. Higell Book Printing.

Soloman, A. (2014). Far from the Tree: Parents, Children and the Search for Identity. Scribner.

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Sensory Processing Disorder (SPD)

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Posted on by Leonardo Rocker (Quirky Kid Staff)

Sensory Processing Disorder in Children

Have you ever wondered why your child over reacts to loud noises, being touched, certain tastes and smells, or bright lights? Research has shown that at least 1 in 20 children experience sensory sensitivities or are affected by a Sensory Processing Disorder (SPD) (Ahn, Miller, Milberger & McIntosh, 2004). SPD is defined as a difficulty receiving, responding to and integrating sensory information necessary to generate appropriate behavioural responses.

Sensory processing difficulties are a common presenting issue at Quirky Kids, as children who are overwhelmed by sensory information often respond with dysfunctional habits and behaviours and may avoid certain experiences. For children with SPD, lights are often too bright, loud noises cause discomfort, and eating a certain food group may cause gagging. Parents often seek assistance for associated emotional, social and educational issues that commonly result from  sensory imbalance. SPD can also commonly co-occur with many other psychological and neuro-developmental disorders such as ADHD, learning disabilities, and post-traumatic stress disorder.

What causes SPD in children?

The exact cause of a SPD like many other neurodevelopmental disorders, is yet to be identified (Miller, 2006). Preliminary research suggests that SPD may have a strong genetic component, with children born to adults on the Autism Spectrum, showing a greater likelihood of developing a SPD (Tomchek & Dunn, 2007). Males also appear to be at a higher risk of developing a SPD than females (Ahn et al., 2004).

Currently, there is some understanding of how the sensory pathways are disrupted in SPD. Our brain and nervous system operate like a computer system, transmitting messages from our senses to our body. These messages form the basis of muscle movement, coordination, learning, memory, emotion, behaviour, and thought. As with a computer, a malfunction in one part of the system typically affects other parts of the system.  When there is a sensory processing dysfunction, the brain does not process or organise the flow of sensory information in a way that gives the child precise information about themselves and their world. As a result, learning can be challenging and children may have difficulty coping with the stress of daily sensory and organisational demands. This often results in additional behavioural difficulties.

 What Sensory Processing Disorder looks like in children?

The symptoms of a SPD exist on a spectrum. SPD may affect one sense such as hearing or taste or it may affect multiple senses. Similarly children can be over or under responsive to sensory stimuli. There are several SPD subtypes:

  1. Sensory modulation: This is where children tend to respond more intensely to sensory input which frequently results in avoidance behaviour. Common symptoms include, withdrawing from light, gagging and resultant refusal to eat textured food, refusal to brush teeth , wash hair, or cut nails and an over-sensitivity to sound or visual stimuli (eg. the child may clasp their hands over their ears or eyes at loud noise or bright light)
  2. Sensory discrimination: This is where children have difficulties with recognition and interpretation of sensory stimuli. Common symptoms include, difficulty following instructions, problems finding images in a cluttered background, using too much or too little force, poor balance, poor sense of movement or speed.
  3. Postural-ocular disorder: This is where children have difficulties controlling or stabilising the body during movement or at rest. Common symptoms include poor posture control, poor equilibrium and balance, fear of heights.
  4. Dyspraxia: This is where children have difficulties in planning, sequencing unfamiliar actions and motor skills. Common symptoms include being accident prone, clumsy, resistant to new activities, and poorly coordinated with fine motor tasks.

Impact of Sensory Processing Disorder in children

Research has shown that many children with a SPD are more vulnerable to experiencing social, emotional and educational problems (Dunn, 1997). Children who are hypersensitive to sound and touch may experience intense affect, often feeling overwhelmed or impulsive. On the other hand, children who are hypo-sensitive may under-react to sensory information, which may be confused for lack of drive, a lack of empathy or being quite self-absorbed.  Many kids with SPD are labeled as ‘clumsy’, ‘disruptive’ or ‘out of control’, and may have problems with the motor skills necessary for school success.  Anxiety, depression, aggression, or other behavior problems can follow.

Treatments for children with Sensory Processing Disorder?

The good news is that there are effective treatments for a SPD.

  1. Psychological intervention can help children get used to sensations they cannot tolerate. Graded exposure to sensory stimuli and teaching coping skills can help overcome avoidance to sensory stimuli. Behaviour modification, using reward charts, can assist in encouraging appropriate responses to sensory stimuli. A Psychologist can also help with the emotional and behavioural difficulties commonly associated with sensory difficulties such as defiant behaviour, anxiety, or school difficulties.
  2. Occupational Therapy (OT) with a Sensory Integration (SI) approach is highly effective for sensory difficulties. Therapy generally takes place in a sensory rich environment sometimes called a ‘sensory gym’. The goal of OT is to foster appropriate responses to sensations in an active, meaningful and fun way so that a child can behave in a more functional manner. Over time (and with practise) the appropriate responses will generalise to other environments such as home and school.
  3. Making a table with many tools and toys may be helpful for children with SPD. A bowl of rice, a bag of beans or play dough can be highly effective tools to help balance sensory needs. Fill a bin with toys and objects of different weights and textures and let your child explore! See http://shopau.sensorytools.net/ for a list of sensory tools.

 

References

Ahn, R. R., Miller, L. J., Milberger, S., & McIntosh, D. N. (2004). Prevalence of parents’ perceptions of sensory processing disorders among kindergarten children. American Journal of Occupational Therapy, 58, 287–293

Dunn, W. (1997). The Impact of Sensory Processing Abilities on the Daily Lives of Young Children and Their Families: A Conceptual Model. Applied developmental theory, 9,4.

Miller, L., Fuller, D.A (2006). Sensational Kids: hope and help for children with sensory processing disorder. Putnam, 1st edition.

Tomchek, S., & Dunn, W. (2007). Sensory processing in children with and without autism: a comparative study using a short sensory profile. AJOT, 61, 190-200.}

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Enconpresis in school aged children

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Posted on by Leonardo Rocker (Quirky Kid Staff)

Understanding and Managing Encopresis in Children

 

Encopresis (or faecal soiling) is one of the most frustrating difficulties of middle childhood, affecting approximately 1.5% of young school children (von Gontard, 2013). It is a debilitating condition to deal with as a parent, as it usually occurs at a stage when children are past the age of toilet training.

Encopresis is a common complaint amongst parents who visit the Quirky Kid Clinic as it often occurs in the context of other behavioural issues such as oppositional defiant disorder (ODD) or separation anxiety.

According to the Diagnostic Statistical Manual (DSM-V) (American Psychiatric Association, 2013) encopresis (or otherwise known as Elimination Disorder) is essentially the repeated passing of stools into inappropriate places, after the age at which toilet training is expected to be accomplished. In order to receive this diagnosis, 4 features should be present:

  • Patients chronological age must be at least 4 years
  • A repeated passage of feces into inappropriate places, which is either intentional or involuntary.
  • At least one such event must occur every month for at least 3 months.
  • The behaviour is not attributed to the effects of substances (e.g., laxative) or any other medical condition.

There are two basic categories of encopresis i) primary encopresis-which refers to children who have never attained bowel control, ii) secondary encopresis-which refers to soiling after successfully attaining toilet control usually brought upon by entering a stressful environment (such as family conflict).

What causes encopresis?

Parents of children with encopresis often feel frustrated as they often believe that their children play an active role in controlling their bowel movements.  While in some cases, soiling may be intentional, in other cases it may be involuntary and beyond the child’s control. It is important to be aware of the many possible causes for this disorder.

  • Biological factors: Functional constipation (persistent constipation with incomplete defecation without evidence of a structural or biochemical explanation) is one of the main causes of encopresis, accounting for 90% of cases amongst children (Har & Croffle, 2010). Children may withhold stools often because he/she is constipated and therefore experiences pain when there is a bowel movement. Chronic withholding of bowel movements causes children to lose the ability to defecate normally, and causes partial bowel movements of which children are often unaware. Other medical causes such as spinal cord damage, celiac disease or damage to the bowel can result in encopresis. Medications may also lead to non-retentive fecal soiling. Tricyclic anti-depressants, narcotics, and iron are likely to cause constipation that is severe enough to lead to encopresis and laxative abuse can cause severe diarrhea and fecal incontinence.
  • Psychological factors: Overall 30-50% of children with encopresis have a comorbid emotional or behavioural disorder (von Gontard, 2012).  In a large population study, school aged children with encopresis had significantly increased rates of separation anxiety (4.3%), specific phobias (4.3%), generalized anxiety (3.4%), ADHD (9.2%) and oppositional defiant disorder (11.9%) (Joinson et al., 2006). Children who present with Oppositional Defiant Disorder or Conduct Disorder (that is, children who are intentionally defiant and non-compliant to their parents or caregivers) may use inappropriate soiling as a form of retaliation, as a means to communicate their anger, or as an attention seeking strategy. There is also evidence to suggest that children who have encopresis experience higher levels of  anxiety and depression as a result, and these symptoms can exacerbate the symptoms of encopresis. A population study by Cox et al., (2002) found that children with encopresis had more anxiety and depression symptoms, exceeding the clinical threshold by 20% compared to control children.
  • Family and social factors: Children may develop delays in toileting due to unsuccessful toilet training as a toddler and intrusive toilet training. It may have been that children recieved discipline for having accidents or have been encouraged into toilet training before they were ready. Negative toilet training practice can cause children to associate using the toilet with punishment. In other cases, encopresis occurs when there is a stressful family situation such as divorce, birth of a sibling or transition to a new school. In severe cases, frequent soiling may occur in a child who has had a traumatic or frightening experience such as a sexual or physical molestation.

What are the potential risk factors for Encopresis?

In western cultures, bowel control is established in 95% of children by age 4 in 99 % of children aged 5 (von Gontard, 2013). Around primary school age (10-12 years old) 1.5% of children develop encopresis. Although every case is different, studies have shown that there are a number of risk factors, which are associated with the development of encopresis including:

  • Gender: encopresis is five times more common in boys than girls.
  • Abuse and/or neglect.
  • Inadequate water intake.
  • Presence of chaos or unpredictability in a child’s life.
  • Lack of physical exercise or a diet that is rich is fat/ sugar.
  • Presence of neurological impairment such as brain damage, autism, developmental delay and intellectual disability.
  • History of constipation or defecation.

What is the impact of encopresis in school aged children?

Encopresis can have a severe effect on the child, family and school environment. Encopresis is often a family preoccupation, as parents and siblings become increasingly frustrated as family activities may be disrupted due to the constant soiling. The family is left fruitlessly battling over the child’s bowel control, and the conflicts may extend to other areas of the child’s life such as school functioning and social circles such as friends. When the child becomes increasingly aware of these difficulties, they may become angry, withdrawn, anxious and depressed and may be a victim of bullying if other peers become aware. Studies have shown that encopresis children experience a greater amount of anxiety and depression symptoms, difficulties with attention, more social problems, disruptive behaviours and lower levels of academic performance (Mosca & Schatz, 2014).

What are the treatment options for encopresis in school aged children?

While encopresis is a chronic and complex problem amongst many families, it is treatable. As a parent, it is important to be aware that there is no quick fix for encopresis, the process might take months and relapse is very common. Sixty-five percent of patients are almost completely cured in 6-months and 30% show improvement (Har & Coffle, 2010).  The majority of children with encopresis can be effectively treated with a combination of medical, psychological and dietary interventions.

  1. Medical treatments: The first step to treating encopresis is to identify the cause behind the condition and seek medical advice from a pediatrician or GP. Medical examinations are important in order to rule out the existence of organic causes. Initially a doctor may prescribe a laxative to ease the passage of the hardened stool through the rectum. Once the stool has passed, substances such as fiber, enemas or laxatives may be used to empty the colon and decrease painful bowel movements.
  2. Behavioural modification with the assistance of a Psychologist is an integral treatment component for encopresis . In order for this to be effective, family tension regarding the symptom should be reduced and a non-punitive atmosphere should be established. Parents should encourage their child to sit on the toilet for 10 minutes after meals 2-3 times a day. The initial aim is to produce a bowel movement by giving the child the chance to get used to using the toilet and to be in tune with bodily cues.  Parents can create a reward system, which provides incentives for the child to use the toilet. He/she may receive a star or sticker on a chart for each day he/she successfully goes to the toilet without soiling and a special reward could be earned after an 80% success rate during the week. A recent meta-analysis by Freeman, Riley, Duke & Fu (2014) found that behavioural intervention is the most effective treatment for encopresis.
  3. Treat other co-morbidities: Comorbid emotional and behavioural disorders should be treated separately according to evidence based recommendations (von Gontard, 2013). If your child is presenting with anxiety, depression, or oppositional defiant disorder, these associated co-morbidities should be treated concurrently to reduce symptoms of encopresis. Untreated co-morbid disorders will reduce adherence and compliance and the outcome of encopresis treatment will not be optimal.

Other tips include:

  • Never tease or embarrass your child and do not show anger. Supporting your child’s self-esteem is essential. Name calling and teasing are frequent results when a child soils at school/and/or smells of feces so it is important that their self esteem is not affected as a result. While it may seem like purposeful behaviour at times, it may not be within your child’s control (as in the case of functional encopresis).
  • Encourage your child to drink lots of water, eat fiber rich foods such as fruits, vegetables and whole grains
  • Consider scheduling evidence based psychological intervention if your child feels shame, guilt, depression or low self esteem related to encopresis.
  • If your child shows no improvement after 6 months they should be referred to a gastroenterologist for additional assessment.

References:

American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Cox, D., Morris, J., Borowitz,S., & Sutphen, J. (2002). Psychological differences between children with and without chronic encopresis. Journal of Pediatric Psychology, 27,7, 585-591.

Freeman,K.A., Riley, A., Duke,D.C., & Fu, R. (2014). Systematic review and meta-analysis of behavioural interventions for fecal incontinence and constipation. Journal of Pediatric Psychology. 39, 8, 887-902.

Har, A.F., & Croffle, J.M. (2010). Encopresis. Paediatrics in review. 31,9,368-3754.

Joinson, C., Heron, J., Butler, U., et al. (2006). Psychological differences between children with and without soiling problems. Pediatrics, 117, 1575-1584.

Mosca, N., & Schatz, M. (2014). Encopresis: Not just an accident. NASN School Nurse. 28,5,218-221.

U.S. National Library of Medicine, MedlinePlus (2012). Encoporesis. nlm.nih.gov. Retrieved 12 September 2014 fromhttp://www.nlm.nih.gov/medlineplus/ency/article/001570.htm

von Gontard A.(2012). Encopresis. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva:

von Gontard, A. (2013). The impact of the DSM-5 and guidelines for assessment and treatment of elimination disorders. Eur Child Psychiatry, 22,61-67.

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