How to deal with encopresis

Dr Kimberley O'Brien (00:04)

Hi, I'm Dr. Kimberley O'Brien, Principal Child Psychologist at The Quirky Kid Clinic. It's a child psychology clinic as well as a publishing house with resources for parents and educators. We help parents to build their confidence in the strategies that they use at home to overcome common issues impacting children adolescents. So for the past 20 years, I've been listening to lots of different stories and giving lots of different strategies, and I hope to do the same on this podcast to help you overcome the challenges that you're facing with your children adolescents. Today's topic is encopresis, with Monica Ferrie, a toilet training educator.

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Monica Ferrie (00:44)

So, encopresis is where a person has a buildup of poo, and I'm going to speak really bluntly and use words like that, so I hope that's okay, a buildup of poo. And as the poo builds up, their bowel stretches and stretches and stretches, so the rectum then loses sensitivity. And it can't actually tell them when it's full of poo, when it needs to poo. And because of that loss of sensitivity and the poo becoming so impacted, poo slips out. And it might be that that's the trigger when a child first realises that they actually need to have a poo, is with that release of a little bit of poo or it might be fecal fluid that just comes out, and that's the clue for the child that they need to go and have a poo.

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Dr Kimberley O'Brien (01:45)

I'm just listening to that and hearing how comfortable you are in talking about it. Because when we see parents at the clinic, it's usually the complete opposite, in that they feel quite embarrassed. And maybe it's something they hadn't spoken about before when it comes to encopresis.

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Monica Ferrie (02:02)

Oh, completely. Yeah, completely. I remember actually a family that came to see us about, and they actually came to see us about toilet training, not toilet training, they came to see us about bedwetting, and this was a little boy who was about seven or eight years old at school, and part of what we would do with a consultation about bedwetting is take a natural history.

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Monica Ferrie (02:28)

So, in asking questions about the child's toileting habits, one of the things that we would always ask is, "Does the child have any issues with pooing?" And in this particular case, we had the mom and the dad and the little boy and asked that question, "Does the child have any issues with pooing?" And everyone in the room goes quiet, looks at each other with anticipation and finally somebody says in quite a almost whispered, "Well, yes, actually he does." "So, what does that look like?" "Oh, he poos himself regularly." "Well, how often?" "Maybe three or four times a week." "And how long has this been going on?" "Oh, since he was about three."

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Monica Ferrie (03:23)

So this poor little child has been going through the distress of pooing himself and at school for the last couple of years, so all of the distress that goes along with that. His parents are unbelievably distressed, because no parent likes to see their child in distress and they haven't really known what to do about it. And it's not something that people spend a lot of time talking to each other about. They think they're the only ones who have ever had a child that has got something that they view as, it's embarrassing, because it's distressing for them and they don't know what to do about it. And there's no conversation, there's no collegiate feel about, I'm not the only one with this problem. There are loads of families with this problem and if they talked about it, they would find there are loads of occasions, loads of families where this is happening.

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Speaker 1 (04:25):

Absolutely. It's interesting and I think parents are often comfortable looking it up on the internet. So that's our number one most popular fact sheet, encopresis on The Quirky Kid website. And I've been contacted by a organisation in the States to do a webinar about encopresis, because it could just be, I'm not sure, but there's been an increase definitely at the clinic with new referrals. A lot of kids are doing things like being online and using their iPads and forgetting to go to the toilet or having these accidents. And then the parents are often there asking, "Is he doing it deliberately," or, "Is this an act of defiance?" "Are they anxious about the toilet?" Like, "What is going on?" Because it's really impacting the parent child relationship and it can also impact social relationships at school because of the smell.

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Dr Kimberley O'Brien (05:15)

Oh, certainly.

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Dr Kimberley O'Brien (05:17)‍

So many different angles for this story.

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Monica Ferrie (05:19)

Yeah, I think it's not deliberate. I have not seen any child who is comfortable with pooing themselves. It is, in our experience about that lack of sensitivity that they have in their rectum. So they actually can't control it and they don't know it's going to happen until it happens. And then, it's all the trauma of having to deal with having the accident publicly. And for a little child, that's an enormous pressure to even anticipate, God, is that going to happen to me today and where am I going to be and who's going to notice? And then having to deal with the outcome of that as well.

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Dr Kimberley O'Brien (06:06)

Absolutely. And interestingly, it also happens to older kids so it can continue. We've had a 12, 13 year old at the clinic that was transitioning from primary to secondary school. And again there's all this pressure around, we have to get this under control. She was wearing pull-ups, well actually she was wearing pull-ups just to go to the toilet. So she felt like she needed that, she felt more comfortable using a pull-up than actually sitting on the toilet. So in her case she was really anxious about being on the toilet. And we did things like cutting a hole when she wasn't wearing the pull-up, we'd cut a hole in the base of it so that she could sit on the toilet and she could use the toilet in a conventional way, but she had the pull-up there just as security. And then over time she reduced that dependence on the pull-up. But it is quite individual, that was one way of managing it for that client. But maybe you've got some other tips that you use for younger kids when it comes to getting on top of encopresis.

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Monica Ferrie (07:02)

So, I think for younger kids where we know that there's been a history of constipation, getting the constipation dealt with rather than being concerned about the actual geography of the pooing, at the beginning is the way that we would recommend you focus. Because that physical problem of constipation is one that in many cases goes on to become a lifelong problem, so it's something that needs resolution. And that resolution is really about a couple of things that need to happen.

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Monica Ferrie (07:42)

So, we need to ensure that fluid intake is really great, because that's really important for constipation in young kids. And often we feed our kids up on fiber because we know that fiber's important, but the younger you are, the more important the fluid is and the fiber without the fluid actually can be problematic. So we need good fluid. We also need our children to become comfortable with just sitting. And you see kids that sit on the toilet for about a second and then they're off and they're so busy doing things, so encouraging children to sit and sit anywhere. So this isn't just about being able to sit when you're in the toilet, but actually being able to stop and sit and be comfortable doing that and relaxed doing that is an important part of being able to toilet and poo properly because to poo, we actually need to relax. So you have to be able to sit to do that.

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Dr Kimberley O'Brien (08:50)

Absolutely. It sounds like the calm down kits that we get kids to put together, a little shoebox full of like a lavender pillow, or a favorite book, or a, there's actually another book that we recommend called 101 Things to Do While you Poo, and there's origami with toilet paper, a whole bunch of different things you can do to help kids to sit a bit longer.

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Monica Ferrie (09:12)

And for older kids that stuff becomes important, because if we can get them to be relaxed and sit on the toilet, because it's often the last thing they want to be doing, there's a million other things that they'd rather be doing than sitting by themselves on the toilet waiting for a poo to arrive. But a program of sitting is often what a GP will recommend. So, to sit half an hour after a meal, so half an hour after breakfast, lunch and dinner just to have a sit. No more than five minutes, we would never be putting pressure on a child to sit for hours, or half an hour, or until they've done something, always about low pressure, low stress, five minutes max. Unless they're really happy to sit there and some kids are, some kids will disappear with a book or an iPad into a toilet, close the door and completely disappear. But pooing's probably not what's on their mind when they're doing that.

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Monica Ferrie (10:16)

The other thing that a GP would recommend is laxatives. And for younger kids in particular, we would be looking for laxatives that are stool softeners, not laxatives that actually cause contractions of the bowel. Because the stool softeners, all they do is draw fluid back into poo. So it's all about making the poo slippery and soft. So that would be what the GPs would be seeking to have happening and fluid intake and the laxatives go together and then that ability to sit.

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Dr Kimberley O'Brien (10:56)

And, Monica, do you know how long kids should be taking laxatives for? I'm not sure whether you've heard different timeframes, but I know in the States sometimes kids would be on laxatives for years at a time and I also think can we put some natural, something more natural, vegetable juice, banana smoothies, just anything to replace the laxatives if it's been quite long term use? But I'm not sure what the ideal is. What's your opinion on that?

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Monica Ferrie (11:21)

So, if we're talking stool softener laxatives, which is certainly what parents should be making sure that their little ones are taking, if they're taking laxatives, it's not unusual for kids to be on those for months. Because they don't cause the bowel to contract, so they're not creating any muscle memory or anything like that, they're just simply putting fluid back into the poo. The other thing which is heading down that more natural path are things like olive oil. So, natural olive oil or organic olive oil is one of the things that some laxatives actually or stool softeners have in them, for example. It's the laxatives that act on the bowel that I'd be more concerned about the length of time that a child was taking them.

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Dr Kimberley O'Brien (12:21)

Okay, that sounds helpful. And also good for parents to consider having a review with their GP or pediatrician booked in once they do start taking the appropriate laxatives, because sometimes I'm thinking it's time for a review because it might not go well. Kids sometimes will have a huge bowel movement in the bath when they haven't really mastered how much or the dose of the laxative and that can then be more traumatic. So I think having a review booked in will then allow the parent to feel comfortable to access extra advice rather than having to wait another six weeks and not sure whether to continue or not. Having that accesability to the GP or pediatrician who is managing the situation is really helpful for some.

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Monica Ferrie (12:43)

Yeah

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Dr Kimberley O'Brien (12:44)

Expecting, they haven't really mastered how much or the dose of the laxative and that can be then more traumatic. So I think having a review booked in will then allow the parent to feel comfortable to access extra advice, rather than having to wait another six weeks and not sure whether to continue or not. So yeah, just having that accessibility to the GP or the pediatrician who's managing the situation is really helpful for psychologists as well, to put in a call and give some feedback and to work together as a team I think is also key.

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Monica Ferrie (13:15)

Yeah, I think a team approach is really important. The other thing I'd suggest in terms of GPs and pediatricians is that if you're at all concerned about the information that you're being provided with or the course of action that you've been provided with, there are pediatricians who specialise in continence. So they actually specialise in pooing and weeing issues, rather than just general pediatrics. And they can be really great, because it is an area of specialisation, so they can be really great to get a referral. There are plenty around Australia who have private clinics as well, but there are many in the public system that a referral can be generated for.

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Dr Kimberley O'Brien (14:05)

Great advice. Now, can I just ask you a little bit more about school, because most of the kids that are experiencing encopresis at Quirky Kid are school aged and this just adds that extra level of complexity. Because sometimes parents are anxious that they won't be allowed to continue at school, or that the teachers are not allowed to change their underwear and things like that. So there's sometimes extra pressure like, we need to get this under control, otherwise they won't be able to maintain that enrollment. Have you heard that, or is it just that some schools are happy to give them access to the teachers' toilet and give them extra pairs of underwear and wipes and things, or is it just dependent on the school?

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Monica Ferrie (14:47)

I think schools are like many communities and many organisations, where schools have great people having bad days who sometimes don't make good decisions. They have not so great teachers having bad days who make even worse decisions. They have great teachers having great days who take great care of our kids. So, that's really unfortunate, because it means that there is an inconsistent experience that could be had in the same school with the same teacher, or in different schools across a large section of the school community. I would be bringing the teacher on board the team with a plan to say, this is what we are actually working towards, your role is to support the child to go to the bathroom, remind them after lunch, half an hour after they've had their lunch, remind them to go and sit, let them out of your class to go and sit on the toilet for five minutes.

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Monica Ferrie (15:52)

So to continue that routine of sitting, but engaging the teacher with a plan of how they can help and what they can do, rather than leaving it up to them to make decisions that they might think are good decisions but may not be the right one for the child in question. So I think that collaborative approach is really important and sometimes tough, because you've got to have a hard conversation with the teacher and hope that there is a level of understanding there. But I do think most teachers really desperately do want to help their kids to have the best possible outcomes.

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Dr Kimberley O'Brien (16:31)

I agree with you for sure. I think that any child that's having problems with encopresis needs all the help they can get and often even their peers are wondering how we can help, shall I go to the toilet alongside of them with a toilet pass? Can we set up a buddy system? There's just so [inaudible 00:16:48].

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Monica Ferrie (16:48)

Yes

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Dr Kimberley O'Brien (16:49)

Need to try and help

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Monica Ferrie (16:54)

That's a great point, because I think for adults we often think, I can't imagine anything worse than pooing yourself in public. But for kids it's not as big a deal as it is adults imagine it to be. So I think that peer support carefully managed, because obviously not all kids are of that ilk, where they would choose to be caring and supportive, but carefully managed I think there's a huge benefit in actually building a peer support around a child who has encopresis.

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Dr Kimberley O'Brien (17:30)

And I think, just the idea of carefully managed and increasing that sensitivity is really important to start early because, I'm just thinking of a family I helped that were a long way away from any face to face consultation, living in a really remote rural area with this issue and having to do video calls with calls dropping in and out, it was quite a challenge to maintain rapport with their teenager who was struggling with this. And in that case he had just lost all sensitivity to the situation. He was so not bothered by it, didn't really want to be on the call. So I think if families are affected by this issue, it's important to get help early, old habits don't take place and kids become really complacent.

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Dr Kimberley O'Brien (18:17)

And the thing that I've found most useful is just trying to increase young people's independence around toileting. So giving them the baby wipes and the plastic bag to put the soiled undies in at school, so they can start to clean themselves up and have their fresh undies available to them, rather than having to ask someone at the office for a fresh pair. And even at home, having everything they need in the laundry to put their underwear in a tub filled with some stain remover and just get the action happening, so they don't have to hide things and feel like they've got to ask [inaudible 00:18:53].

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Monica Ferrie (18:52)

Yeah

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Dr Kimberley O'Brien (18:52)

Assistance

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Monica Ferrie (18:53)

I think too, what that does is it empowers them to have a positive impact in what is essentially, I think what they would see as a really negative experience. But it gives them some control back because they actually, they can't control the fact that they have pooed themselves, but then they can control what unfolds after that. And I think that's really important for us to be teaching our kids and giving our kids the toolkit to be able to take that responsibility.

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Dr Kimberley O'Brien (19:27)

And also probably last but not least, but the parent factor. I find some parents are almost in tears when they say, if I have to wash another pair of undies. I can't stand the smell. I throw them all out. This can be really overwhelming for parents when they expect the toileting issues to be mastered at the age of three or four and then the kids are up to 13, 14, it can just be so overwhelming. So I think a huge support network for the parents and tag teaming with the cleanup is important. And giving them permission to, yes, buy new undies, you don't need to necessarily clean every single pair

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Monica Ferrie (20:01)

Totally

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Dr Kimberley O'Brien (20:02)

Parents do need all the help they can get, otherwise that resentment then trickles down onto the kids and the whole family, siblings can blame one kid, say, well we could go if it wasn't for you.

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Monica Ferrie (20:11)

Yeah

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Dr Kimberley O'Brien (20:11)

So yeah, I think it's the whole system that we need to look at.

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Monica Ferrie (20:15)

It's really easy as well, if a system like that isn't in place, it's really easy for it to become the focus of the whole family. It finds its way into every conversation. It finds its way into every bit of planning for the future. So it's always the elephant in the room, but it's consciously spoken about where everybody in the family's in on that discussion, where I think that's not valuable. It is something that will resolve. It is something that for a while needs to be managed until that sensitivity returns, and it will return. So if the constipation can be dealt with, the rectum will return to being able to manage that physically. So it's really important that that support is there during the time while that resolution is taking place. But to not have it the focus of everybody's discussion, everybody's, that constant, oh my god, we've got to deal with this, I think is really an important piece of the puzzle too.

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Dr Kimberley O'Brien (21:27)

Yes, I agree. No shame and best discussed in a confidential setting with experts who deal with this kind of issue all the time.

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Monica Ferrie (21:34)

Yeah. Yeah.

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Dr Kimberley O'Brien (21:36)

Thanks so much for your conversation today, Monica. It's so good to connect with someone who's dealing with similar things.

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Monica Ferrie (21:42)

Yeah, I think a collaborative team approach to being able to support our parents and our young ones is getting more and more important every day.

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Dr Kimberley O'Brien (21:52)

Here. Here. Thanks, Monica.

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Monica Ferrie (21:55)

You're really welcome.

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Dr Kimberley O'Brien (21:57)‍

If you'd like more resources on encopresis, head to The Quirky Kid website and you'll find a million different fact sheets there. And as I mentioned, the most popular one is the encopresis one. You can also check out the webinar I did recently, which has videos on techniques we use in the clinic to address encopresis.

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Dr Kimberley O'Brien (22:14)‍
For our next episode, we'll be talking about separation anxiety. I'm Dr. Kimberley O'Brien. See you then.

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