About 5-20% of ALL encopresis cases are nonretentive encopresis and have no physical condition that bars normal toileting behaviors. This type, functional encopresis, is a behavioral condition in which the child refuses to defecate in a toilet.
The information presented here are general guidelines and are meant to provide you the parent with some knowledge and information, so that you can have a more informed conversation with your physician or your child's pediatrician.
While 99% of the cases of non retentive encopresis do not have an organic / medical basis, however the 1% of the cases do. Medical reasons such as
- irritable bowel syndrome
- severe ulcerative colitis
- acquired spinal cord disease (i.e. sacral lipoma, spinal cord tumor)
- rectoperineal fistula with imperforate anus
- postsurgical damage to anal sphincter
may be causing your child to withhold his Bowel Movements. These medical reasons can be diagnosed and treated by your child's pediatrician
The other and more likely reasons for nonrententive encopresis are:
- that the child may not be developmentally ready for potty training
- the child may have emotional or behavioral disturbances such as Oppositional Defiant Disorder or Conduct Disorder
- the child refuses to defecate in a toilet because he is afraid. The child will urinate in the potty or toilet, but will refuse to poop in the potty or the toilet. Some children will also refuse to poop in the underwear and will only poop in a pull up or diaper. Yet, other children will simply refuse to poop at all and end up with chronic constipation.
Encopresis Causes:
The remaining cases have no physical condition that bars normal toileting behaviors. This type, nonretentive encopresis, is a behavioral condition in which the child refuses to defecate / poop in a toilet.
A child may exhibit nonretentive encopresis, or functional encopresis, for several reasons.
First, he or she may not be ready for toilet training or rather bowel training . When the child is potty trained, they will learn to urinate in the potty or toilet, but will fail to be bowel trained.
Second, the child may be afraid of defecating or of the actual potty or toilet. The fear may that the bowel movement will be painful or be painful is he or she is sitting or maybe painful on the toilet. Some children are afraid of the toilet in public places and will only defecate at home..
Others may use fecal incontinence to manipulate their environment, parent or other adults.
Last, but not least, it may be because the child has irritable bowel syndrome.
Although the behavior patterns and toileting dynamics of children with nonrentive or functional encopresis are well defined and most pediatricians are aware of these issues with children, not all physicians are well equipped to treat this condition.
Encopresis Treatment: In the absence of fecal impaction or chronic constipation, the pediatrician may have to engage an pediatric psychiatrist or a behavioral counselors to determine the underlying cause of the nonretentive encopresis.
Once the cause is determined, the psychiatrist, psychologist or behavioral counselors can decide on the specific treatment options.
For the 1% of nonretentive cases that are organically or medically based, the pediatrician would have to engange the appropriate specialist in those area for treatement options.
For the child that may not be developmentally ready for potty training (see child readiness section), the best option is to allow the child to mature physiologically, as well as cognitively, emotionally and socially. The child can also be taught the necessary motor and verbal skills required to for potty training.
For children with disruptive behaviors and childhood noncompliance across mutliple settings (e.g. dressing, bath time, bed time, eating etc.); the larger context of the child's behaviors have to be addressed before attempting toilet training. A child has to be cooperative and compliant to adult instructions for successfully potty training and bowel movement training. A pediatrick behaviral psychologist would be best for determining the treatement options.
Many children with nonretentive encopresis have a history of painful defecation, toilet phobia or toilet refusal behavior. What drives these children is fear. So the treatment for these children to address their fear.
Start by keeping a diary or a journal or chart of your child eliminations - both urination and bowel movements . Do this for 1-2 weeks. Log the time when he urinates or has a bowel movement and where he eliminated i.e did he do in the toilet, in his bed, in his underpants etc. If your child is day care during the day, ask the teacher to look for patterns in your child's toileting behavior.
Positive toilet sits are one strategy to help children overcome their negative association of the bathroom. The goal of positive toilet sits is to have the child associate the bathroom and the toilet with a positive and enjoyable experience. The startegy is schedule 3-5 sits per day at the family's convenience. Initially, the sites are very short (i.e. 30 seconds) and then gradually increase the sits to a maximum of 5 minutes. The child can remain in his underpant or diapers and there should be not expecatation of producing a bowel movement. The child is encouraged to sit on the toilet, while comfortably resting his feet on a step stool and enjoys relaxing one on one activity with a parent such as reading or singing or talking.
If the child is extremely resistant to approaching the bathroom or the toilet, then the parents should employ the gradual shaping method. The parents start by modeling the appropriate toileting behavior for the child and after a few days of this, the parents should start playing games or reading books with the child near the bathroom. The parent and child should gradually progress to where the child is sitting on the potty chair or the toilet for longer periods of time.
While the parents are working on positive toilet sits and positive association, it is critical to ensure that the child is having relatively frequent, soft and well formed bowel movements beofre engaging in any intervention for soiling.
Dietary changes, use of supplements such as flavored fiber drinks, bran sprinkles, prunes, prune juice etc may be needed to increase the number of bowel movements.
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