The school holiday period can be a great time to reflect on the last term, prepare for upcoming changes and review skills that need to be improved.
Returning to school is typically experienced with mixed emotions. For some parents, it is a welcome relief after what feels like a very long holiday. For others, the return to school signals the end of a carefree, relaxing break and there can be feelings of sadness and/or anxiety associated with the return to routine and the academic and social demands associated with the school.
Children and young people equally experience a range of feelings about the return to school. For some, there is great excitement about starting a new school, seeing friends or perhaps finding out who their new teacher will be. For others, there may be sadness about the end of the holidays or anxiety about a raft of possible concerns such as making friends in their new class or coping with the work/homework requirements.
A tried and test way to prepare for changes and transitions is by focusing on your child’s social and emotional adjustment.
Tips to Help Your Child Settle Into Term 3
Whilst a lot of focus is placed on the academic tasks associated with school, paying particular attention to a child’s social and emotional adjustment over the coming weeks/months is also critical. Below are 3 tips to get you started:
Make time to check in with your child about how they are feeling and coping with the school year so far. It’s important to really listen to what your child is saying. To do this, begin by just repeating back or paraphrasing what your child is telling you. Where your child is experiencing uncertainty try to normalise this and remind your child that it can take a few weeks to really settle in. It is not uncommon for children (and parents) to express disappointment about a new teacher they may have been assigned or about the discovery that they don’t have as many close friends in their class. Rather than jumping to solve the problem for your child, build resilience by encouraging your child to come up with some ideas about ways to help themselves cope in such a situation.
It can often be a good idea to make time to check in with your child’s teacher as soon as terms resume. Whilst you will, of course, wish to discuss their educational strengths/weaknesses, also address how your child is feeling about their progress and to highlight anything (e.g. camp, homework) that may be worrying your child. Make sure you also discuss your child’s social skills with the teacher. If they are struggling with friends, ask your child’s teacher how the school can help in facilitating friendships. If your child has had any ongoing incidents of bullying/teasing it is critical to mention this again and ask how they can help to ensure that such incidents don’t occur again during the next terms. Equally, if your child has a history of seeking attention from others in a class by misbehaving, check on how this is been handled at school. Teachers will undoubtedly find your insights into what works and what doesn’t work at home very useful.
Encourage friendships and further consolidate social skills in by organising playdates or outings with any new classmates made throughout the term. Whilst children often request existing friends, it can be worthwhile trying to extend friendship networks by inviting new children over. This is not only good for your child but can also help to expand social support networks for you as a parent. In secondary school, it is equally important to encourage friendships by providing opportunities for your son/daughter to have friends over or by offering to drive them to a movie etc. This not only helps foster friendships but also gives parents valuable insights into the type of friendships that your child is building.
Why social-emotional learning is so important
The importance of focusing on the social and emotional well being of children is becoming increasingly acknowledged. In the current climate of increasing rates of mental illness in young people and concern over youth suicide rates, the NSW government has reportedly decided to tackle the problem more aggressively by proposing to adopt a more preventative approach in addressing such issues. The Government’s decision to begin at the grassroots level and start better-educating school-aged children (from Kindergarten) about mental health issues is welcome news to everyone here at Quirky Kid.
The changes to the Personal Development, Health, Physical Education (PDHPE) syllabus which are apparently due for implementation from 2020 include a more comprehensive effort to address social-emotional learning and mental health issues from primary school onwards. Beginning in Kindergarten, it is proposed that children will begin with simple social-emotional concepts such as feelings and building relationships with others, but as they progress to higher grades the aim will be to address important issues such as coping with success and failure, overcoming adversity, grief and death, coping with controlling behaviour in others, domestic violence, and substance abuse.
Helping Children to Build Important Social-Emotional Skills
Equipping children to cope with the social and emotional demands of school fosters increased coping and resilience skills. The evidence suggests that well developed social and emotional skills are both protective and helpful. Strong social and emotional skills in children not only predict fewer behavioural problems in the classroom but they are also related to positive academic outcomes and improved school performance (Myles-Pallister, Hassan, Rooney, & Kane, 2014; January, Casey & Paulson, 2011; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011)
The government and other mental health agencies hope that by tackling such topics in school and by better-educating children about mental health, steps will be made to not only demystify such issues but will crucially equip children with a more effective toolkit for managing difficult feelings. It is further hoped that lessons learned at school will have a lasting impact as children become adults.
How Can Quirky Kid help develop your child’s social-emotional learning skills?
At The Quirky Kid Clinic, we are strong advocates for prevention and early intervention when it comes to children’s mental health issues. Prevention, is, of course, the preferred approach. In our experience, providing intervention to children and families before problems become too entrenched can often be the key to success. Where issues have been developing for some time, it can be much harder to address problems and for both the child and family such situations can feel insurmountable.
The Best of Friends® gives children the knowledge skills and confidence to understand and manage emotions, set and achieve positive goals, develop and maintain friendships and make good decisions. Designed for children aged 7 to 11, the program teaches these critical skills to children in an age-appropriate and practical way.
So embrace this potentially challenging time with your son/daughter and remember children tend to take the lead from their parents. With this in mind, try to model calm, brave behaviour whilst at the same time keeping the doors of communication wide open. By adopting these strategies your child should feel a little braver about adapting to their new classroom, teacher and school expectations.
Term 3 Social and Emotional Learning Programs for Children
Durlak, J.A., Weissberg, R.P., Dymnicki, A.B., Taylor, R.D., & Schellinger, K.B. (2011). The Impact of Enhancing Students’ Social and Emotional Learning: A Meta Analysis of School-Based Universal Interventions. Child Development, 82(1), 405-432
January, A.M., Casey, R.J., & Paulson, D. (2011). A Meta-Analysis of Classroom-Wide Interventions to Build Social Skills: Do They Work?. School Psychology Review, 40(2), 242-256
Myles-Pallister, J.D., Hassan, S., Rooney, R.M. & Kane, R.T. (2014). The efficacy of the enhanced Aussie Optimum Positive Thinking Skills Program in improving social and emotional learning in middle childhood. Frontiers in Psychology, 5, 909.
Greatness comes in many forms and is quite subjective depending on an individual’s age and abilities. For a child overcoming anxiety, greatness may be winning a public speaking competition or finding the courage to confront a new fear. For others, greatness may reveal itself through academic or sporting achievements, kindness, creativity or thoughtful leadership. In any case, discovering one’s unique strengths or passions is easier with the help of a caring coach, an attentive teacher, or a dedicated parent.
According to a recent survey of Australian students in Year 4 to 12, parents and teachers are the greatest influencers of a student’s sense of satisfaction and fulfillment (State of Victoria, Dept of Education and Training, 2017). Therefore, it is essential for parents and teachers to give sound advice on the subject of achieving greatness as defined by the child.
Leadership expert, Robert Kaplan (2013), developed a roadmap for reaching potential. In brief, he suggests greatness is achieved when we know our strengths, take the initiative and connect our daily actions to a clearly defined goal. For most children, defining a goal is easy but taking the initiative to make it happen is usually dependent on the adults around them. That’s where we come in!
Here’s what you can do:
Foster their self-belief. For example, if you know a child who aspires to be a professional soccer player, help them find a great coach or coaching clinic. For those with more left-of-centre skills outside the areas of sporting or academia, keep an open mind to the activities available that might help push their strengths to new levels. Show them that you believe in them and make it happen!
Research together. Show young people how to take the initiative by helping them to research and connect with experts in their field of interest. A child with a passion for making robots would be forever empowered if you showed them how to contact the Head Inventor at Battlebots. Imagine if they said yes to a Skype call?
Use a wide-angle lens. Think broadly when it comes to inspiring young people. Be proactive and organise a range of guests to visit your school to spark an interest in every child. These could include artists, refugees, adventurers or someone with a “diffability” who is pursuing a passion. You never know when inspiration will strike!
Set an example. Take on a challenge of your own and you will inspire others to do the same. Show some initiative and take steps on a daily basis to reach your goal. Share your journey’s highs and lows with the young people around you and make haste towards your destination.
Work together. Challenges aren’t meant to be simple, but staying focused on the task at hand is easier when those around you are doing the same. Achieve greatness among your classmates, family or friends and your success will be even sweeter!
Our online Performance Psychology program Power Up! has been specially created for kids who want to push their performance skills to the next level. Power Up! gives them the power to: build self-confidence, cope with the pressures of competition, overcome self-doubt and negative self-talk, set goals and make plans to achieve them and maximise performance in any chosen field.
Kaplan, R.S. (2013) What You’re Really Meant to Do: A Roadmap for Reaching your Unique Potential.Ebook. HBR.
Right School-Right Place (2017) State of Victoria. Department of Education and Training (Vic).
Working with children and their families is a very stimulating and rewarding experience. At the Quirky Kid Clinic, we embrace the uniqueness each child brings to our clinic and ensure all treatment and intervention is tailored to match the needs of each family. As clinicians, we use a wide variety of techniques and I’d like to share one with you.
The ‘All About Me’ Map
Engagement is a foundational and fundamental part of treatment. As clinicians we know how important it is to build engagement with a child before more formal therapeutic work begins. Research tells us that there is a significant positive relationship between the therapeutic alliance and treatment outcomes (Lambert & Barley, 2001).
My first session with a child is always about engagement, hearing all about them, the things they love, the important people in their life and the things they would like some help changing. Children often find it difficult to talk with a stranger in the first session and that is why we use our paper and textas to draw a special Map, all about them.
This activity typically provides enough space for children to be open and engaged, as children focus on drawing and writing, with no pressure to make eye contact with the clinician, who is positioned alongside the child and offers assistance with writing if the child requires.
How it’s done:
The Map typically starts with the child being asked to draw a circle in the middle of a big piece of butcher’s paper and then to write their name and age in the middle.
From there, the child can draw a map, full of mountains, oceans, or all the things they love or places they don’t love so much, with each used as a discussion point for the clinician. Remember to be curious! General areas that could be covered include things that the child enjoys, extracurricular activities, school, friendship connections and supports.
Some questions I ask to help children reflect upon what they enjoy (and to add to their map) include:
If it were raining outside and you had to stay indoors all day, but you could choose to do anything you liked, what would you choose?
If it were a mum day, what would you and mum choose to do together?
Who do you hang out with in the playground, what do you do?
Is there anything important that I haven’t asked you about that needs to go on your map?
After we have completed all the things that the child enjoys or things that are going well, we might draw some waves or special areas that the child chooses, to include the things that the child would like some help with.
Questions I ask around are:
Are there things that you might worry about, what about at school, home, with others/friends?
What sorts of things might make you feel angry?
Do you ever feel sad? What about?
If you lived in a perfect world, what sorts of things would have to change to make it perfect?
This activity is also helpful in assessing things from the child’s perspective, garnering the child’s level of insight, assessing whether the child’s goals align with the parental goals for treatment, allowing the child time to express the things they might be concerned with and offers hope to the child that you understand them and can support them.
[00:00:00 – 00:01:16]Kids nowadays are more exposed to lots of screen time and parents are using this technology to effortlessly help in getting kids preoccupied, however this can result into massive meltdowns.
Reporter:What do you think about the modern day relationship between children and technology?
Dr. Kimberley: I often see kids using – well not often – but like, it’s becoming more regular that you see kids even as young as 2 using like, iPads, either in restaurants or while their mum’s are waiting in line, you know, in the waiting room at our clinics as well.
Kids are getting exposed more and more to screen time obviously and parents are using it as a way to keep the kids preoccupied. And, I think that’s great, except that there are usually some massive meltdowns involved – that I’m sure parents can relate to. As soon as they need to like pack up and go, and take the iPad away, these meltdowns are worse than your average tantrums. Because there is quite an addiction involved, you know, when it comes to the bright light, then in the middle of the game where you have to go through those stages to get to the next level again. So I think for parents, the tantrums can be more stressful because they last longer and are a whole lot louder. My advice would be try to avoid giving screens to kids under the age 5 because we can easily keep them entertained if we give them a book, and then you don’t have the meltdowns afterwards. Or even just a fiddle toy would do. There’re so many other options to avoid screen time that you can also carry in your handbag.
[00:01:17-00:02:37] This technology is damaging to the cognitive and social development of these kids thus giving them limited interest to interact with other kids or adults.
Reporter: In terms of long-term development, is it detrimental to their cognitive and social development?
Dr. Kimberley: I think so. What I see, even in 15 years olds who have been doing a lot of gaming for long periods of time, is that they have really narrow group of friends with narrow interests. So they might have one close friend that they do lots of “gaming” with on the weekends (I’m probably not using the right lingo).
But, if it doesn’t have a screen and they have to go or something, like if it’s someone’s birthday, then it’s just so hard for them to be there. It just feels more boring than it would have if they didn’t have such narrow interests because their social skills have been depleted and they haven’t been practicing on weekends, or having more conversations with people of different ages about different topics, because of their narrow interests.
So we do see fifteen year-olds to want to broaden their interests, but that can be quite a challenge because they have to actually do stuff that they don’t enjoy to start with, the enjoyment will grow when they develop new network of friends and they get more physically be able to run, jump or climb, so that can get back to a normal balanced lifestyle.
[00:02:38 – 00:04:18]Kids these days have serious addiction to technology and it is making them more aggressive.
Reporter: So you think that addiction to technology is real and it’s happening at the moment?
Dr. Kimberley: Yeah, definitely.
I saw a really good documentary but I wasn’t able to find it since I watched it. It was based on a Chinese rehab program for adolescent boys that have screen addictions. These are boys that have been gaming all through the night, have dropped out of school and have been spending like, 22 hours a day on screen. Some of them doing things like peeing in a bucket, wearing adult nappies so they didn’t have to come away from the screen. They serious wanting to be the best in world at whatever they were doing.
In that documentary they were in full withdrawal when they have no access to a screen, and two of them in that period of time, like in that one month program, they broke out and they went straight to an internet cafe and started playing, trying to catch up after being away from it so long.
Yes I do see it as a serious addiction. You want to watch it, because they’re some really lovely kids that we worked with in that middle range, from 10-12 years old. Just lovely kids that are well educated. They have supportive families, but are becoming more aggressive, throwing huge rocks through the sliding glass doors trying to get back inside once mum gives up because of too much screen time on a Saturday morning. Or breaking into a filing cabinet trying to get the laptop, fully busting the lock, doing damage.
[00:04:19 – 00:04:27]Kids who have attachment to technology are showing aggressive behaviours thus causing damage.
Reporter: In terms of behavioural issues, there is obviously the attachment to technology but you are saying there’s aggression as well?
Dr. Kimberley: Yes definitely.
[00:04:28 – 00:05:06]Technology is not the main cause of decreasing attention span of children, there are also other factors to consider.
Reporter: I’ve read a study that the attention spans of children are decreasing because of technology. Do you find that this is true?
Dr. Kimberley: It could be hard to pinpoint that as a cause and effect because there are just kids with short attention spans, with or without technology. But I think teachers are using more technology in the classroom and then, I suppose when they turn the screens off, they have to be, you know – I mean it’s great to watch a YouTube video of something and then to have the teacher try explain every word, but it doesn’t have such an impact. I imagine the kids would become more accustomed to seeing things move and hearing different voices and different scenes. It’s hard to compete with.
[00:05:07 – 00:05:50]There are pros and cons in using technology in teaching. There are games that are educational that can help kids with spelling, reading, and mathematics.
Reporter: Do you think that technology should be used in school for children in reception like iPads and that kind of thing?
Dr. Kimberley: I know some school mums are sometimes annoyed at teachers that are giving little girls, like kindergarten/year 1/year 2, a lot of time on screens because that is something that they have tried to win as off time and only use it on weekends or something like that. And when they drop in to do reading at school and some kids spend the whole hour on screen and they feel that is not teaching. So, I think you get mixed reactions. Or the kids might love doing those educational games there are really some good ones out there that can really help children with spelling words, reading, mathematics. So there are pros and cons.
[00:05:51 – 00:06:30]Technology is beneficial for children but you have to managed the use of it.
Reporter: So do you think overall the increase use in technology is beneficial to children or detrimental?
Dr. Kimberley: If it’s managed, then beneficial, totally. I think it’s a great reward for kids to get all their homework done, and then have some time to do something they really enjoy. And to use it as a reward and use it in limited periods of time so that they don’t develop that addiction. I think they get used to logging off after 5 t0 10 minutes – it not such a big drama, but if it’s been 4 to 5 hours, thats a whole waste of the weekend I think. And it’s not the right parenting in my opinion. Reporter: Yes, fair enough.
[00:06:31 – 00:06:57]Children in general should only be allowed to have screen time for 1 hour every day.
Reporter: One last question – so how long should children in general be spending on screen everyday?
Dr. Kimberley: Research says maximum of 2 hours but for me that feels like high school age when they have laptops and homework to do online and things like that. So I think two hours for those kids who have to do homework online. But for other ones, maybe two hours on weekends and one hour every day.
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.
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.
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.
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.
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.