Treatment for Non-Rententive Encopresis

Although the toileting dynamics and behavioral characteristics of children with non-retentive encopresis are well defined, few specific treatment guidelines are available for family physicians, meaning your physician may not be as helpful as you would like!

The American Academy of Family Physicians has 6 guidelines for dealing with this condition.

• Identify Potential Medical, Developmental or Behavioral Pathology.
• Address Toilet Refusal Behavior.
• Ensure Soft, Well-Formed Stools
• Schedule Prompted Toilet Sits
• Provide Incentive for Appropriate Bowel Movements and Self-Initiation
• Arrange for Physician Contact in Case of Stool Withholding.

Identify Potential Medical, Developmental or Behavioral Pathology.

Before you should come up with a plan to address this issue, it is vital that you and your doctor have done a complete medical evaluation and know for sure that there is no medical reason for your child's encopresis. á

Once we've ensured that your child is soiling for a non-medical reason, the second thing that needs to be addressed is your child's development. What is the right age for potty training? Is your child developmentally ready to be potty trained?

Not only must your child have the necessary physiological development for potty training(bladder and bowel control), but he needs a degree of motor, cognitive and verbal development that some children don't attain until they've reached three or four years, along with a well-developed sense of social conventions. The Potty Training Readiness Signals will help you determine if your child is the developmentally ready for potty training.

The third thing that needs to done is a behavioral assessment. If your child has a pattern of disruptive behavior across multiple settings (such as dressing, bed time, meal time, and others), then their behavior pattern as a whole needs to be addressed before potty training can be specifically addressed. Your child need to be cooperative and compliant to adult instructions and should be able to consistently follow parental instructions in a timely manner.

The last thing that needs to be done is to have daily toileting diary for your child. The diary will help in planning the next steps.

Address Toilet Refusal Behavior

Children with non-retentive encopresis tend to have a history of painful defecation, toilet phobia, and toilet refusal behavior. To overcome these negative associations, you can schedule what the AFP calls "positive toilet sits".

Basically, these are short sessions in which your child sits on the toilet while engaging in a relaxing, enjoyable activity such as reading or talking with you (see our great selection of Children's Potty Training Books).

Your goal during these is to help your child associate the toilet with pleasant, pressure-free situations. Start with very short sits (for example, 30 to 45 seconds) and gradually increase the duration, up to five minutes, preferably using a timer to signal completion.

If your child is extremely resistant to approaching the toilet seat, you can employ what the AFP refers to as a "gradual shaping procedure". Start by modeling appropriate toileting behavior for a few weeks, then begin playing games or reading books with your child in or near the bathroom.

You should then gradually progress to engaging in these activities while your child is sitting on the potty chair, and from there, gradually increase duration. Fathers, it is recommended that you sit while modeling the urinating process. 

Ensure soft, well formed stools

Before any sort of intervention, it's critical to ensure that your child is having soft, well-formed bowel movements. You may find it necessary to change your child's diet or introduce supplements like flavored fiber drinks or bran sprinkles(see our diet ideas).

If your child still isn't producing soft and well-formed bowel movements, you might want to consider stool softeners or laxatives. On the flip side, these supplements are likely to make it more difficult for your child to withhold their bowel movements, meaning they'll have more soiling accidents.

It's a very good idea to develop a standard clean-up procedure that you can direct your child through and be emotionally neutral about. Don't criticize or blame your child for their mistake.

Schedule Prompted Toilet Sits

Once your child is comfortable with the toilet and having comfortably soft and well-formed bowel movements, you can start scheduling prompted toilet sits during which your child is likely to defecate(see our Potty Chairs and Potty Seats).

Schedule prompted sits five to twenty minutes after each meal and during other high-frequency opportunities indicated by your child's daily toileting diary.

Once your child has achieved regular bowel movements on the toilet, you can have a "graduation ceremony" of sorts where you can inform your child that they're now a big boy and diapers will no longer be used. (See our selection of Potty Training Pants)

Don't make the mistake of using diapers when convenience seems to necessitate it (e.g. family outings). This sends a mixed message to your child about toileting expectations.

Provide Incentives

Once your child has proven that he or she is capable of using the restroom for bowel movements, it's possible to use an incentive program to reinforce appropriate potty behavior. Incentives are most effective when they're age-appropriate and consistently and promptly given after every occurrence of the desired behavior.

Whatever the incentive (candy, stickers, other temporary rewards, and even special time with parents or peers are possible ideas), access to it should be restricted whenever proper toileting behavior has not been exhibited.

Once your child is using the toilet regularly, you'll want to gradually cut down on verbal prompts to use the bathroom, train the child to be aware of the need to urinate or defecate and request to use the bathroom, in order to ensure that your child is using proper hygiene. 

Arrange for Physician Contact

In case your child continues to withhold, you should arrange to contact the physician if your child withholds for four consecutive days. Your physician will likely prescribe a daily regimen of laxatives or stool softeners, like in guideline 3.

If withholding leads to impaction, enemas, suppositories, mineral oil, and electrolyte solutions are all possible solutions. Once the impaction is eliminated, your child can return to their daily regimen of stool softeners or laxatives.  

For more information on this subject, please see Chapter 4.8 Encopresis.