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.
Some girls are feisty from the get go, from fussy babies to tantruming toddlers. The pre teen or “tween” years though, can be the time which parents find most confounding. At this time parents can struggle with everything from girls (and boys) becoming increasingly defiant to the ‘sexualisation’ of young girls and navigating increasingly complicated relationships with peers.
Between the ages of 8 and 13, children are expected to push the boundaries and this is a part of becoming more independent. You can therefore expect girls at this age to disagree with you, show a bit of ‘attitude’, take risks and want to be more like their friends. Remember, “this too shall pass”. In the meantime, you can support your child by guiding her behaviour with clear rules, warm relationships and an understanding of why teenagers behave the way they do.
For example, their brain are still developing: the ability to control our impulses does not fully mature until 25! Pre teens and teens, therefore, are more likely to make decisions based on emotion and have poor foresight. They are also often sensitive, moody and unpredictable. This poor ability to foresee consequences and make informed decisions can be offset by helping to build a pre teen’s confidence so that she can avoid bad situations, bad relationships and be able to say no.
Just because they are getting older doesn’t mean your girls don’t need rules and boundaries. Instead of imposing these on them, set agreed limits that teach independence, responsibility and problem solving. This will lead them to develop their own standards for what is appropriate and how others should be treated. Praise and encouragement, of course, is still important at this age so let her know what she is doing right. Also, although rude and disrespectful behaviour is common at this age that doesn’t mean it should be acceptable. Collaborate with your child on rules about this type of behaviour and then model what you would like to see youself. In the moment, stay calm and wait for the right time to talk about it. When the situation has cooled and can be talked about, let her know how you feel e.g. “I feel hurt when you speak to me like that.” Fighting between siblings is also common at this time and is a normal part of growing up which teaches us life skills like conflict resolution.
The pre teen years are a time when girls are dealing with peer pressure, possibly bullying or cyberbullying and the need to begin taking risks. An increasingly important role for parents and other adults at this time is to help girls to develop a positive self image. It is difficult for them to ignore the messages from TV, music, movies, the web and clothing stores which sometimes encourage girls to be “sexy” and base their self worth on how they look at a time when they are not physically or emotionally ready. The belief held by young girls that they must dress a certain way to fit in is part of growing up. They feel pressure to conform because dress is part of their social code. As parents we can tune in to media that is targeting our girls and then talk to them about it.
Talk about the qualities they value in their friends and how important these are versus physical attractiveness.
Have conversations about TV shows, dolls and outfits that you don’t like instead of giving a blanket “no” and encourage activities where she excels that take the focus off looks and being cool.
Most importantly, don’t lecture! Ask for your girls’ opinion and try to listen more than you speak. At this time it is also important to not avoid sex education but rather find out what the school is teaching so you can follow up at home. This goes beyond “where babies come from” and is about choices, behaviour and relationships. Ask your daughter’s opinion about these things, she is probably just as conservative as you are! Overall, be a healthy role model and avoid talking about feeling “fat”, “ugly” or going on diets around your daughter.
The pre teen years are a time when we expect girls to get a little feistier but some will show this more than others. Disruptive behaviour is known to pass through generations so if you were a feisty young girl there is a good chance your daughter will be too. You can buffer against this by fostering a warm relationship and setting firm but fair boundaries. Remember to talk to your girls so you can support them through what can be a tough time. You may sometimes get a ‘brick wall’ but meet them where they are by setting aside special time and being available when they come to you.
Helping girls develop a positive self image. Australian Psychological Society (website)
Molen et. al., (2011). Maternal Characteristics Predicting Young Girls’ Disruptive Behaviour. Journal of Clinical Child and Adolescent Psychology. 40 (2), 179 – 190
Pre-teens behaviour: in a nutshell. Raising Children Network (website)
Sexting, a name given for the creating and sharing of sexually explicit pictures or messages through mobile phones, the internet and other electronic devices, has become an increasingly recognised and concerning pastime of children.
It is estimated that in 2012, over 20% of teenagers engaged in sexting, with a higher prevalence reported among girls. In a survey carried out by a popular girls magazine in 2010, around 40% of girls reported that they had been asked to send sexually explicit photos of themselves, with the majority of girls complying, citing fears about disappointing or aggravating their male peers as reasons for engaging in sexting.
Along with the negative emotional consequences that often accompany sexting experiences, such as feelings of embarrassment, regret and anxiety, are also an increased vulnerability to being exposed to cyberbullying and more serious legal ramifications.
Current legislation states that the taking, sending, receiving or possessing of naked or semi-naked images of someone under the age of 18 years can lead to a child pornography charge and placement on the Sex Offenders Register. Australian law does not distinguish between sexting and more serious sexual crimes such as paedophilia and there are no minimum age requirements, such that a young person under 18 years can be charged and placed on the Register.
Sexting between consenting persons always carries the risk of being made more public and attracting cyberbullying attacks. For example, images may be passed through social networking sites without consent and attract derogatory, abusive and vicious attack. Cyberbullying can have a significant impact on young people, with the potential for reputations to be destroyed and for young people to experience social isolation and depression as a consequence.
Why do young people engage in sexting?
A common question among clinicians, teachers and parents is why do young people engage in sexting when the consequences for doing so seem so negative?
Some answers commonly given by our young clients are that they do not view semi naked and naked images as wrong or shameful, typically viewing these images as more of an expression of fun and flirtation. Developmentally, expressing oneself sexually in the teenage years is considered to be common and normal. With recent statistics showing us that around 78% of Australian students between Years 10 to 12 engage in some form of sexual activity, sexting appears to be one way our young people are expressing their sexuality.
Additionally, young people are seeing images of their role models engaging in sexting themselves (eg. sports celebrities), such that there is a culture of acceptance and a visible lack of understanding around the real consequences so often involved in sexting experiences.
This raises an interesting question as to what safe and secure ways can young people be expressing their sexuality without attaching shame, negativity and embarrassment to the experience?
Some positive ways parents can address sexting are:
Discuss the issue of consent with your young person: Saying “no” in the face of peer pressure is a difficult territory for young people to navigate. Help your child identify times in which they may be exposed to peer pressure (eg. parties) and what they can do to resist the peer pressure, such as seek out a helpful friend, make an excuse to exit the party, say “no” assertively.
Educate yourself: young people are typically very savvy with technology and it is up to parents to be vigilant and learn about new technologies and stay up to date with the latest trends. When young people have the privilege of having a phone or device from a young age, conditions must also be implemented to protect the young person’s safety, such as parental monitoring of the phone.
Educate young people: Discuss with your child the social, emotional and legal risks associated with sexting and the possible future consequences. Make a plan with your child rather than lecturing them, get them to come up with what is appropriate and discuss openly any times they have engaged in sexting and the reasons for doing so, such as being peer pressured. Overcome your embarrassment about talking to your kids about sex and how they can protect themselves and keep your emotions calm.
Help your young person to stop and assess: develop clear boundaries around what your young person can and can’t do on a device and help them develop a clear understanding of what they should do if taking a selfie and/or receiving a sexually inappropriate message. For example, wait and think before sending, assess whether the image could be inappropriate in any way, show a parent before sending or upon receiving an image that could be inappropriate.
Engage school support: Schools have a variety of supports that can be helpful when addressing sexting among young people. For example, schools often have access to a Police Liaison Officer, who can be engaged to discuss sexting and cyberbullying with the students and be involved in individual cases if need be. As cyberbullying frequently involves peers, schools can aid parents in addressing the problem if it arises.
Address things when they arise: be alert for any signs that your young person is engaging in or receiving sexually explicit images. Often parents hope that the issue will resolve itself, however, picking up early warning signs that your young person is engaging in sexting can lead to to far better outcomes. You may be prompted to open up communication with your child about sexting if they are being more secretive and defensive around their device, agitated after using their device, selective around what pictures they show you, withdrawing from friends and seeming depressed for example.
Balancing young people’s right to privacy and their right to safety is one of the many challenges parents face. Providing focused guidance and support around how young people can use their devices in a safe and responsible manner needs to be an ongoing conversation in our families.
Fisher, S., Sauter, A., Slobodniuk, L. & Young, C. (2012). Sexting in Australia: The Legal and Social Ramifications. Parliament of Victoria Law Reform Committee Sexting Inquiry.
Svantesson, D. (2010). ‘Sexting’ and The Law. How Australia Regulates Electronic Communication of Non-Professional Sexual Content, Bond Law Review, 22 (2), 1-17.
Crofts, T. & Lee, M. (2012). ‘Sexting’, Children and Child Pornography. Sydney Law Review, 35 (85), 85-106.
Children are more likely to behave the way we would like them to when we create an environment that reduces opportunities for challenging behaviour. This means an environment that is rich in age appropriate, stimulating experiences but also one that minimises “triggers” for challenging behaviours like tantrums, aggression and defiance. The most important part of a child’s environment are the relationships that inhabit it. Relationships that are built on warmth and mutual respect will teach children prosocial behaviour and encourage them to live up to our expectations. Prevention is better than cure so with a few measures in place; an environment can be created in which behavioural challenges are less likely to arise, and we can be better prepared to respond when they do. So how do we create this environment?
Rules that are clear, reasonable and meaningful, help children to understand what is expected of them and provide you with simple reminders that you can give to children before situations get out of hand. Afterall, how can we expect them to behave in a certain way if we haven’t told them what that is? Only a few rules are needed and ideally, children will be involved in creating these as part of a team effort. You may even like to write up a family contract to sign and display somewhere in the house, (make sure the grown-ups sign too)! Keep the language positive and make it a project that everyone wants to be a part of.
Children are more likely to follow a rule if they feel an agreement has been met rather than that they have had something imposed upon them. Also, decide and make clear what the consequences will be for breaking the rules and always remember to follow through. Logical consequences like removing a toddler from the sand pit when they are throwing sand at their sibling work best for younger children and time-out can be helpful from about three years if used appropriately (e.g. one minute per year of the child’s age and minimal interaction so that the situation can defuse). Withdrawal of privileges such as loss of Gadgets time is only effective once the child is old enough to link their behaviour to a consequence that occurs later in time (about six years and up).
To be meaningful for children, consequences need to be immediate. It is most important that when enacting rules and boundaries parents are predictable and consistent. Studies have shown that children can sense when one parent has a different parenting style to another and this can lead to an increase in behavioural and emotional concerns.
Teach and support communication
Behaviour is communication. Usually, children behave in a certain way to tell us something and achieve a certain goal. They haven’t learnt the communication skills to tell us what is bothering them or what they need, and so they show us through their behaviour. As long as the message is getting across and their needs are being met the behaviour will continue. Look for what the message is behind the behaviour and help children to build their emotional language “I can see you are very angry!” Give them an alternative, more appropriate, ways to communicate as you support them in navigating the purpose behind their behaviour. This may be through the use of visual prompts or teaching and practising specific skills such as asking for help with a difficult task that would normally lead to frustrated outbursts. This goes both ways; it is important not to assume that communicating verbally is enough to tell a child what they need to know. Timers, visual schedules and stop signs are great tools for this. Quirky Kid has developed a tool called Tickets, to assist parents to do just this. It is popular and worth a try.
Provide Emotional outlets & Play!
Give children a chance to let it all ‘hang out!’ Children get stressed, anxious and frustrated just as we do so plenty of opportunities to express this in a safe and appropriate way will decrease the chance of these emotions bubbling over. Put on some music, paint, draw, dance and sing. Stomp around like angry monsters or just go for a run outside. Play is also an important way for children to learn emotional regulation, problem-solving and social skills. Take the opportunity to play with your child and hand over the controls. Giving them a chance to lead you in their choice of games is an excellent way to give children the sense of control that they often seek.
Catch them getting it right
Children seek out both positive and negative attention and can draw their parents in by doing the wrong thing. Be mindful of this and avoid giving attention to this kind of behaviour, consider giving yourself a time out if you need to. Save your attention for the behaviours you would like to see more of.
We almost certainly will tell a child when they are doing the wrong thing, but what about when they get it right? Plenty of specific, meaningful praise will remind children of the kind of behaviour you like to see and will encourage them to continue in the same way. Tell them exactly what would like to see more of, e.g.
“I really love the way you took your plate to the dishwasher before I had to ask, thank you!”
“That was such a kind thing to say to your sister, you have been playing together really nicely today.”
Reward schemes can also be helpful when you are trying to target a specific behaviour. Agree with your child on a reward that is meaningful to them and remember to reward but never bribe! As with consequences for challenging behaviour, rewards should be immediate. Also, they should not be taken away once they have been earned. Again, Quirky Kid has developed a tool called Tickets, to assist parents to do just this.
Know yourself and your triggers
Tired? Stressed? Had a bad day? Be mindful of how this can affect the way you respond to your child’s behaviour. Think about what your buttons are and how you can respond with a level head when they are pushed. If you feel yourself being drawn into an argument, take a step back and try not to react in an emotional way as this usually adds fuel to the fire. Having some pre-planned strategies of how you will respond when certain behaviours occur will help you to feel calm and in control.
Finally, remember to look after yourself! Talk about that enormous tantrum and how it made you feel with someone you trust. Laugh about it, cry about it and take the time to refill your cup by doing the things you love. Think of the team of adults you have around you; consistency across parents and other caregivers will help support you in supporting your child.
Australian Psychological Society. Parent Guide to Helping Children manage Conflict, Aggression and Bullying www.psychology.org.au/tip_sheets
Berkien et al. (2012) Children’s perception of dissimilarity in parenting styles are associated with internalizing and externalizing behaviour.
Brotman et al. (2011) Promoting Effective Parenting Practices and Preventing Child Behavior Problems in School Among Ethnically Diverse Families From Underserved, Urban Communities.
Sutherland & Conroy (2012). Best in Class – A classroom based model for ameliorating problems behaviours in early childhood settings.
This post was produced by Quirky Kid and first published at the Essential Kids website Gratitude is a positive way of thinking and viewing the world. Raising a grateful child is a hard thing to accomplish in a culture that wants everything now and is quick to move onto the next best thing but gratitude is an important life skill. By learning gratitude, children learn to become sensitive to the feelings of others, developing empathy and other life skills such as the ability to view situations positively. Grateful children begin to learn to look outside their one-person world. When a child does not learn gratitude, there is a risk that the child may end up feeling entitled and perpetually disappointed.
Research suggests that gratitude is something that many adults have not yet developed and find difficult to practice. Children who are encouraged to be grateful throughout childhood, will typically be more appreciative later in life. A 2003 study at the University of California in Davis, showed that grateful people report higher levels of kindness, happiness and optimism. A little sacrifice causes us to miss things that we take for granted …
Strategies to Develop Gratitude
The research tells us that ‘gratitude’ is not an inherent natural behaviour, rather it is a learned behaviour. It is also important to remember that each developmental stage impacts on the capacity the child has to think ‘outside themselves’ and consider others.
We can begin to teach our children gratitude from a young age through modelling. Parents have to model behavior they hope their children adopt as their own. A simple, sincere expression of gratitude when your child does something they were asked to do is always appropriate. On the contrary, demanding ‘thanks’ from your children does not assist nurture the growth and development of gratitude.
We can begin to teach our children, and ourselves, how to think gratefully, by practising the following skills;
Teach our children to focus on the positive and find gratitude. This can be done by creating a gratitude journal and can be done as a family. Reflect together on the best parts of the day. This teaches children to pause and think about the good things in their day. Also, redirecting children’s attention to all that they currently have, rather than ‘what they want’.
Celebrate the ‘small’ things. Help your child focus on the things they have achieved, whether big or small. Sharing successes with family members and friends, keep a special folder or box and collate ‘keepsakes’ which help the child remember what they have achieved, the positives in their lives and the happy experiences and memories.
Teach through example. If you notice a lack of the gratitude attitude, consider teaching through example. Responding in a grateful way, and labelling this ‘gratitude’ behaviour will assist your child learn the ‘how to’ of gratitude.
Establish family rituals. By having family rituals which centre around gratitude, children learn to express thanks. Examples of family rituals include, each family member listing one thing they were grateful for during their day, or, writing thank you notes to each other once a week.
Try going without. From time to time, consider a family project that involves going without something important. For example, try making bread for a week rather than buying it, or try walking in your local area, rather than using a car. A little sacrifice causes us to miss things that we take for granted and helps us be a more humble and grateful when the thing is restored.