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.
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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.