Clinical Reference Systems: Pediatric Advisor 10.0

DESCRIPTION

A child with encopresis passes part or all of his normal bowel movements into his underwear or diaper rather than the toilet. This guideline discusses children who have this problem but are not constipated.

CAUSE

When encopresis begins suddenly, the cause is usually a new stress in the child's life. The stress may be a physical illness such as severe diarrhea or an emotional upset such as the birth of a sibling. These children usually regain control of their bowels when the stress is reduced or removed.

The most common cause of long-standing encopresis is resistance to toilet training. Many of these children also refuse to sit on the toilet or will use the toilet only if their parent brings up the subject and marches them into the bathroom. Any child who is over 2 and 1/2 to 3 years old, healthy, and not using the toilet after several months of encouragement to use it can be assumed to be resisting using the toilet.

The most common cause of resistance to toilet training is that a child is strong-willed and has been reminded or lectured too much. Some children have been forced to sit on the toilet against their will, occasionally for long periods of time. A few have been spanked or punished in other ways for not cooperating. Many parents make these mistakes, especially if they have a child with a difficult temperament. Most children less than 5 or 6 years old with encopresis are simply engaged with you in a power struggle. More practice runs, such as you have used in toilet training, will not help. Instead, your child now needs full responsibility and some incentives to spark his motivation.

HELPING YOUR CHILD OVERCOME SOILING

Children who have chronic encopresis can be helped with the following suggestions. If your child holds back bowel movements (BMs) and becomes constipated, medicines will also be needed.

1. Transfer all responsibility to your child for using the toilet.

   Your child will decide to use the toilet only after he realizes that he has nothing left to resist. Have one last talk with him about the subject. Tell your child that his body makes "poop" every day and it belongs to him. Explain that his "poop" wants to go in the toilet and his job is to help the "poop" get out. To help him function independently, put him in loose-fitting underwear or training pants (not diapers or pullups). Tell your child you're sorry you punished him for not using the toilet, forced him to sit on the toilet, or reminded him so much. Tell him from now on he doesn't need any help from you or other people. Then stop all talk about this subject. When your child stops receiving attention for not using the toilet, he will eventually decide to use it to gain some attention.

2. Stop all reminders about using the toilet.

   Let your child decide when he needs to go to the bathroom. He should not be reminded to go to the bathroom nor asked if he needs to go. Your child knows what it feels like when he has to "poop" and where the bathroom is. Reminders are a form of pressure, and pressure doesn't work. He should not be made to sit on the toilet against his will because this will give him a negative attitude about the whole process. Don't accompany your child into the bathroom or stand with him by the potty chair. He needs to get the feeling of success that comes from doing it on his own and then finding you to tell you what he did.

3. Give incentives for BMs in the toilet.

   If your child has a BM in the toilet, give him immediate positive feedback, such as praise and a hug. This positive response should occur every time your child uses the toilet. Special incentives, such as favorite sweets or video time, can be invaluable for helping a child change a bad habit. For using the toilet, err on the side of rewarding generously; for example, you might give your child 20 M&Ms. If you want a breakthrough--that is, use of the toilet for the first time--make your child an offer he can't refuse. Perhaps you'll let him watch a new video he has been talking about. A grab bag containing a variety of treats is also a powerful motivator. On successful days, also consider taking 20 extra minutes to play a special game with your child or take him for a walk to the playground.

4. Give stars for using the toilet.

   Get a calendar for your child and hang it where he sees it all the time. Place a star on it every time he uses the toilet. Keep this record of progress until your child has gone 1 month without any accidents.

5. If your child has never sat on the toilet, try to change his attitude.

   First, give him choices by asking if he wants to use the big toilet or the potty chair. If he chooses the potty chair, be sure to keep it in the room he usually plays in. Your child may need a pleasant reminder once a day when he is clearly having an urge to go. You can say "The poop is trying to get out and go in the toilet. The poop needs your help." Ask him to play the "see if you can poop before the timer goes off" game and set the timer for 5 minutes. Then let your child decide how he wishes to respond to the pressure in his rectum. Some children temporarily may need treats for simply sitting on the toilet and trying.

6. Use diapers and pull-ups as little as possible.

   If your child refuses to sit on the toilet, having bowel movements in diapers is better than holding back the BMs. However, don't let your child wear diapers all day. Keep your child in loose-fitting underwear or training pants, so that he has to decide each time he has an urge to pass a BM whether to use the toilet or to come to you for a diaper. To help him make the right choice, offer major incentives for using the toilet successfully--for example, a trip to a favorite restaurant, ice cream stand, or the zoo.

7. Help your child change his clothes if he soils himself.

   Don't ignore soiling. As soon as you notice that your child has messy pants, clean him up immediately. The main role you have in this new program is to enforce the rule "we can't walk around with messy pants." Make changing pants a neutral, quick interaction without any show of anger. If your child is soiled, he will probably need your help with cleanup, but keep him involved. Have him rinse the soiled underwear in the toilet. He may think this is "yucky" and be motivated to keep his pants clean. If he refuses this task, however, don't force him to do it.

8. Respond gently to accidents.

   The responses to soiling listed below will only delay successful training and may cause emotional problems:

   • threatening or lecturing your child
   • forcing your child to sit on the potty chair
   • punishing or scolding your child for accidents
   • keeping your child in wet or soiled pants
   • giving frequent reminders
   • allowing siblings to tease your child.

9. Ask the preschool or day care staff to use the same strategy you are using.

   Ask your child's teacher or day care provider to let your child go to the bathroom any time your child wants to. Keep an extra set of clean underwear at the school or with the day care provider. Ask them to read this discussion of soiling. Be sure your baby sitter knows how to handle the situation positively and will not punish your child for soiling his pants.

CALL YOUR CHILD'S PHYSICIAN DURING OFFICE HOURS IF:

• Your child holds back his bowel movements or becomes constipated.
• The resistance is not improved after 1 month of following these suggestions.
• The resistance has not stopped completely after 3 months.