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Encopresis: Its Potentiation, Evaluation, and Alleviation
Symposium on Behavioral Pediatrics
Encopresis: Its Potentiation, Evaluation, and Alleviation Melvin D. Levine, M.D.*
"When I first got to Groton I had led so sheltered a life and was so shy that I was afraid to ask where the bathroom was. Hard as it may be to believe, I did what had to be done in my pants or in the bushes. I suppose I was surrounded by foul smells. Holding back as long as I could, I started to suffer stomach pains. Not knowing the cause, school officials suspected homesickness (well, I was homesick; at home I knew where the bathrooms were) and asked my parents to take me home for a few days to ease my adjustment". JAMES RooSEVELT
My Parents: A Differing View
Children with encopresis lack control over their bowels, having forsaken or never gained this most primitive form of efficacy. Commonly, the adult world indicts them for their habit, so that affected children are apt to see themselves as culprits, as prime agents in a self-destructive process. Ironically, they usually are innocent. Children commonly acquire the problem as a result of various combinations of unforeseen circumstances, constitutional predispositions, unintentional practices, inappropriate situations, and misunderstandings. Encopresis is defined as the deposition of formed or semiformed stools in a child's underwear (or other unorthodox locations), after the age of four years on a regular basis. Children generally have their "accidents" late in the day (between 3:00 and 7:00 P.M.). 8
The Question of Subtypes A number of attempts have been made to classify types of encopresis. Some authors differentiate between primary (or continuous) and secondary (or discontinuous) forms. 6· 13 The former describes a clinical picture that has been present "since birth"; in other words, the child has never been trained. Secondary encopresis is said to be a condition of children who have been completely toilet trained and subsequently regress to incontinence. Other authors distinguish between encopresis and fecal soiling, based on the extent to which full bowel movements are passed. Such subtyping, how*Associate Professor of Pediatrics, Harvard Medical School; Chief, Division of General Pediatrics, The Children's Hospital Medical Center, Boston, Massachusetts Pediatric Clinics of North America-Vol. 29, No. 2, April 1982
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ever, may not conform to clinical experience, since in long-standing cases symptoms commonly fluctuate over time, varying in the degree and frequency of incontinence. The same child at different times may stain or soil, produce small rock-like masses or clog the plumbing, or intersperse some relatively normal movements. Traditional classifications based on onset may also be misleading, since a significant subgroup of younsters may fall somewhere between the primary and secondary groups, having been partially bowel trained.
THE CLINICAL PICTURE Encopresis has been said to occur in 1.5 per cent of second grade youngsters. 3 The ratio of boys to girls varies from study to study, but has been placed at 6 to 1. The disorder shows little or no preference for social class. There is no evidence that it is related to family size, ordinal position of the child in the family, or age of parents .I As noted, virtually all children with encopresis retain stools, at least intermittently.12 This proclivity may be subtle and clinically elusive. Vague historical documentation, along with a normal abdominal and rectal examination, may prompt the clinician to describe a child as having "encopresis without constipation." Frequently, in such cases, a plain x-ray film of the abdomen will expose considerable fecal retention. It is common for children to gradually develop "occult" constipation or stool retention that may be asymptomatic or manifest itself as recurrent abdominal pain. Some such youngsters, may, in fact, defecate every day, but produce bowel movements that are incomplete. Their stool retention may not be severe enough to alter physical findings. Some children have predominantly rectal constipation, so that palpation of the abdomen reveals little. A rectal examination in such cases also may be difficult to interpret. As symptoms progress, sensory feedback from the bowel becomes impaired. The rectal wall is stretched and unable to contract forcefully enough. There is increased water absorption from fecal material, leading to ever harder and larger feces. Painful defecation may ensue and even promote anal £issues or hemorrhoids. This labored unpleasant process results in further avoidance or economy of toilet use, thereby engendering increased obstipation. Soon the anal canal becomes stretched and foreshortened. The function of the external and internal sphincters is compromised, allowing the passage of soft feces and mucus around impactions. Paradoxical sphincteric function leads to maladpative alterations of normal defecation reflexes. Physiological pressure : volume relationships are often impaired, such that an increase in the bulk of material within the rectum results in reduced (rather than higher) pressure generation by voluntary and involuntary musculature. It is likely that as better techniques are developed to evaluate bowel motility, a variety of physiologic derangements (both acquired and congenital) will be found to cause or predispose to encopresis.
Associated Symptoms Children with encopresis show a wide range of symptoms. In addition to their incontinence, some suffer from recurrent abdominal pain. They tend
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to be youngsters with a fairly recent onset of stool retention and incontinence. Those with long-standing encopresis generally have acquired tolerance to colonic distention, and seldom complain of pain. The prevalence of enuresis in children with encopresis varies from study to study. In some instances, a distended rectum may result in diminished bladder capacity and some urinary "dribbling" during the day. Treatment of the stool retention frequently alleviates the urologic symptoms. In many respects, encopresis is a "mirror image" of enuresis. In the latter, nocturnal symptoms are far more common. Encopresis at night is relatively rare and seems to have a poor prognosis.
Impact on Life Style and Affect Few children with encopresis harbor the symptoms in isolation. 11 • 14 Preexisting, concomitant, or secondary maladaptive traits are commonly encountered. An inability to control defecation is, of course, humiliating. Affected youngsters live in constant fear of discovery, of exposure, of ruthless peer ridicule. Self-esteem declines, and social withdrawal, anxiety, depression, and extra-abdominal somatic symptoms may occur. Acting-out or sociopathic behaviors are not frequently found in children with encopresis; they are more likely to isolate themselves to varying degrees and show excessive dependency. Commonly, encopresis engenders conflict, accusatory crossfire, as parents, grandparents, neighbors, and professionals advance often contradictory theories about why the child soils. Family activities may be compromised out of fear that the affected child could mess himself in the car, at a friend's house, or in a restaurant. Siblings may hesitate to invite friends home because of offensive indoor odors. Children with encopresis frequently bear cruel nicknames invented by their siblings and peers. A variety of coping mechanisms may be appropriated to deal with this. In most cases, affected children are unwilling or reluctant to discuss such ridicule with adults. A unique feature of encopresis differentiates it from most other functional disorders; namely, youngsters so afflicted almost never have knowledge of any others. Parents also are likely to be unaware of its existence as a common childhood problem. In many cases, they attribute the condition to laziness or poor hygiene and are reluctant to bring it to the attention of a physician. Personal shame and cultural taboos also may cause a family to delay in seeking help. All too often children with encopresis are indicted by the adult world. They are admonished and told they mess to get attention or because they are lazy. A child may be condemned for not returning promptly from play to use the toilet, despite his pathetic and totally honest lament: "I didn't feel it coming." He may be charged with negligence for not changing foul-smelling undergarments after an accident. Parents may fail to recognize that the olfactory sensory apparatus accommodates to odors that are present incessantly, that people have limited awareness of their own body smells, and that consequently a child with chronic incontinence is insensitive to the offensive odor of his own products! In appreciating the agony of encopresis, one must be sensitive to a human condition in which a child may be ridiculed, shamed, or blamed for
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something he did not cause and over which he had had little, if any, control. Such an intolerable predicament may be the most painful concomitant of incontinence.
PATHOGENESIS: STAGES AND POTENTIATION The symptom of incontinence represents the end result of the interplay of multiple factors whose cumulative impact potentiates the condition. Three developmental periods are critical in the generation of encopresis (Table 1). Stage I (Early Experience and Predisposition) covers the first 2 years of life. Stage II (Training and Autonomy) includes a span from 2 to 5 years. Stage III (Extramural Function) encompasses early school years. As children pass through these stages, constitutional predispositions, circumstances of environment, and critical life events may converge to potentiate a functional bowel disorder. In all likelihood, a youngster with only one potentiator can overcome or bypass such susceptibility. Most children with encopresis, on the other hand, appear to harbor multiple potentiating factors, the existence of one or more seeming to increase vulnerability to others. The time of onset of bowel difficulties provides pathogenetic clues. At The Children's Hospital Medical Center, a standardized questionnaire and manual have been developed to help clinicians probe the sources and describe the manifestations of a child's encopresis.I0 The following is an elaboration of commonly encountered potentiating factors at the three developmental stages. A particular child may begin to show vulnerability at an early Table I.
Potentiation of Risk for Encopresis*
Stage I Potentiators. Infancy and Toddler Years Simple constipation Early colonic inertia Congenital anorectal problems Other anorectal conditions Parental overreaction Coercive medical interventions Stage II Potentiators. Training and Autonomy-2 to 5 Years Psychosocial stresses during training period Coercive or extreme permissive training Idiosyncratic toilet fears Painful or difficult defecation Stage III Potentiators. Extramural Function-Early School Years Avoidance of school bathrooms Prolonged or acute gastroenteritis Attention deficits with task impersistence ? Food intolerance, including lactase deficiency Frenetic life styles Psychosocial stresses *Children who ultimately develop encopresis are likely to have accumulated multiple risk factors on this list.
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age and thereby become susceptible to the later acquisition of further potentiating factors. On the other hand, some children may not show their susceptibility until Stage II or Stage III. Stage I. Early Experience and Predisposition Children whose past history suggests significant bowel dysfunction during infancy and the toddler years may be revealing a constitutional or congenital predisposition to encopresis. A condition of "early colonic inertia" has been described as an endogenous tendency toward immature or generally inefficient function. 4 The disorder is common. In some instances it may result from genetic factors, whereas in other cases it may take the form of simple functional constipation from other causes. Most often this is a transient phenomenon, one that becomes a potentiator of encopresis only in the presence of other negative forces. Some youngsters with encopresis have a history of imperforate anus or related congenital anomalies, for which they have undergone corrective surgical procedures. The later development of encopresis may result directly from anatomic alteration or, alternatively, from the psychological aftereffects of early intervention in this region. Other more minor medical problems also may engender infantile difficulties with defecation. Specific food intolerances may be associated with constipation. Ordinarily these problems are inconvenient but self-limited, but in some cases they may be the start of a pathologic chain reaction culminating in encopresis. When there is a constitutional predisposition, further potentiation of encopresis in this age group may be induced by parental overreaction, as extremes of grief or exultation surrounding defecation may engender excessive bowel preoccupation on the part of a developing child. Aggressive management may also lead to dysfunction: overindulgence in suppositories and enemas, digital manipulation, and other coercive offenses may create a socalled "anal stamp." As one author has observed: "The battle of the bowel seemingly won in the nursery is destined to be lost on the playing fields at school." 1 An infant or toddler may himself potentiate impaired function through voluntary withholding. Defecation starts to be perceived as a negative experie.nce; the child strains excessively during bowel movements. Such exertion occurs with the legs hyperextended, creating the impression of a struggle to defecate, but, in reality, the act is an effort to retain rather than expel. Fissures and other forms of perianal irritation may result from constipation and, in themselves, potentiate chronic bowel difficulty by futher encouraging withholding. The preventive implications of such early potentiators are clear. In particular, consistent, low-key, and nonaggressive management of simple bowel problems is likely to minimize potentiation of an underlying susceptibility to encopresis. Stage II. Training and Autonomy During the preschool years, children explore new frontiers of autonomy and independence. To a developing child, bowel training and the newly acquired control it offers represent a major forward step. To some vulnerable
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youngsters, however, approaches to the toilet are marred by fear, by exaggerated power struggles, and by fantasy. During this stage children who have demonstrated bowel vulnerability earlier in life (i.e., during Stage I) are the most likely to continue to accummulate potentiating factors. A child who has integrated negative associations with defecation may be predisposed to fear the toilet, as that receptacle comes to symbolize one further hazard surrounding the unpleasant process of elimination. Apprehension regarding the toilet may constitute an initial potentiator of dysfunction in a child who has no previous history of bowel problems. Some youngsters, when they are trained on a toilet seat, have difficulty performing a Valsalva maneuver with their feet suspended in air. They might be very grateful for the use of a bench, some telephone directories, or any other forms of foot support. In the absence of this, there may be a lingering fear of falling in and of being flushed down. In some cases a child is trained to use the toilet but continues to harbor irrational fears regarding it. There may be fantasies about commodes that overflow and flood the bathroom, about sea monsters that bite when one sits down, or about babies being born in toilet bowls! Some apprehension is normal; in certain children the fear is excessive and culminates in long-standing often unconscious avoidance of defecation. Some do not avoid the toilet totally, but spend as little time there as possible, ultimately developing a routine of incomplete defecation. The immediate result is obstipation followed later by encopresis. Reluctance to defecate in the toilet often may occur as a result of psychosocial stresses coinciding with training efforts. It has been reported that inappropriate training techniques (especially extremes of coercion or permissiveness) also induce avoidance. 7 During Stage II, it is possible that certain medical conditions, such as chronic diarrhea from any source, may induce negative associations with defecation and a consequent potentiation of bowel dysfunction. A variety of potentiators can act upon underlying toilet fears and improper training. Where there are parent-child conflicts over autonomy and dependency, latent bowel dysfunctions may be activated. In a family in which there are constant battles over feeding and/or sleeping, the bathroom can evolve into still another combat zone! It should be emphasized that these conflicts need not constitute evidence of serious family psychopathology. Frequently, they are the results of misunderstandings, misplaced child rearing priorities, and inappropriate advice. Once again, it is likely that anticipatory guidance and parent education can prevent many cases of encopresis.
Stage III. Extramural Function During the early elementary school years, children who have had other potentiating factors may be predisposed to encopresis. New stresses come into play. The most important of these is school. In particular, school bathrooms are a common potentiator of encopresis. A child who is accustomed to defecation each morning at home may enter school and observe that there are no doors in front of the toilets, or that the school lavatory is the theater for a varied program of humiliating scenerios. Such a youngster may become
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determined to withhold defecation until back in the private safety of his own home. By 3:00 P.M., however, he has lost the urge! After several months in this holding pattern, the child may be obstipated and show paradoxical or overflow incontinence. It is not unusual during this stage for children with previous potentiation to begin to have encopresis immediately following a prolonged medical illness such as gastroenteritis. In such instances, normal bowel rhythms may be disturbed, and the child may not be able to compensate. When encopresis is potentiated during the school years, a number of factors are likely to operate. The loss of rectal and anal sensation described earlier is a complicating factor, as is the diminution in colonic muscle tone. A child's own anxiety about the symptom, aggravated by external stresses and pressures, worsens the condition. Dietary indiscretions, such as excessive ingestion of milk or chocolates, tend to exacerbate the problem. Children with a predisposition to bowel dysfunction who also have attention deficits or hyperactivity are particularly prone to develop encopresis. Such youngsters are globally task impersistent. They seldom finish anything they start, and that includes defecation! Thus, day after day, they have incomplete bowel movements, they steadily become constipated, and they eventually are incontinent. A similar phenomenon may be encountered in some susceptible boys and girls whose encopresis is potentiated by a frenetic lifestyle. Thus, a child who is late getting up in the morning and skips defecation in order to catch the school bus may chronically withhold as a result, meeting a tight schedule with an equally tight sphincter! Once again, it is likely that such a youngster will be found to have other potentiating factors if he is to develop encopresis.
General Considerations A multifactorial model is needed to account for the symptom of encopresis. It is inappropriate and unfair to prejudge a child with this problem. Many youngsters whose life adjustment is perfectly normal in all other respects develop encopresis as a result of potentiating forces beyond their control and that of their parents. In other instances, encopresis may be one manifestation of a more generalized picture of maladjustment and psychosocial stress. It follows that each case needs to be individualized, and it should never be assumed that a child with bowel incontinence is "emotionally disturbed."
CLINICAL EVALUATION The assessment of a child with encopresis should include careful consideration of the staged potentiators elucidated above. In addition, it is helpful to survey the range of current clinical manifestations and the forms of past or present management. The following questions should be answered as part of such an assessment: 1. To which developmental stage can one trace the origins of this youngster's difficulty? To answer this, one should examine carefully the age of onset of bowel-related symptoms. Have such problems been present
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since early in life? Was the onset associated with training efforts? Has this child ever been fully trained? Did entry into school or some other critical life event or transition coincide with the first evidence of bowel dysfunction? Did this youngster have any medical treatment or condition that may have resulted in an early "anal stamp"? 1 What other potentiating factors have been present? 2. What is the child's current pattern of toilet use? Does he or she avoid the facility totally or even partially? Is such reluctance confined to certain specific sites (e.g., school)? Are bathroom visits only very brief? 3. What is the current severity and pattern of this child's incontinence? Is incontinence limited primarily to the afternoon and evening? Does incontinence occur daily and fairly consistently throughout the week or, alternatively, is it a sporadic symptom? Are the accidents full bowel movements, just smudges, or mostly stains? 4. What psychosocial conditions in the child's environment may be promoting or aggravating the symptom? Is there marital strife? Are there problems with a sibling? Have there been serious setbacks for this family? Are there indications of deprivation or abnormal patterns of nurturance? 5. Are there characteristics of this child that may be aggravating encopresis? Does the youngster appear to be significantly depressed? Does the child have social interactional difficulties? Is this a youngster who has significant attention deficits, such that task impersistence interferes with establishing a normal bowel routine? Are there associated learning disabilities? 6. What has been the toll of encopresis for this child? Has the youngster developed secondary maladaptive strategies? Has there been some secondary gain from the symptom that is likely to impair speedy resolution? What associated patterns of behavior have emerged-perhaps in response to the child's encopresis? 7. How have the child and family coped with the symptom? Have consistent measures been employed? Has the problem caused considerable disagreement and strife? Is there guilt and accusation associated with the problem? How does the child cover up the disorder? 8. What is the child's understanding of the problem? Why does she or he believe that bowel control has been lost or does not exist? How directly can the child confront and talk about it? . 9. Why do the parents feel that the child has encopresis? What do they believe are the underlying causes? The answers to these questions are helpful in establishing a therapeutic alliance and in understanding the plight of a child with encopresis. Treatment and counseling plans should derive from such information. A complete physical examination should serve to rule out pathologic causes of stool retention and overflow. It should be recognized, however, that in the school-aged child pathologic causes are extremely rare. The sceptre of Hirschsprung's disease frequently overshadows encopresis. Clinicians should be aware of the great difference between the two conditions. These are reviewed in detail elsewhere. 12 Children with encopresis generally are well-nourished and healthy during the school years. A child with Hirschsprung' s disease at this age is likely to appear wasted and chronically ill and to have had intermittent obstructive symptoms. Children with enco-
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presis often have a history of having passed very large bowel movements (sometimes plugging the plumbing); those with Hirschsprung's disease are more likely to produce thin, ribbony stools. Incontinence is the most prominent symptom in children with encopresis; in Hi~schsprung's disease heavy soiling is unusual. Children with encopresis may have acquired their bowel symptoms relatively late in life, whereas those with Hirschsprung's disease commonly present with serious bowel problems in early infancy. The physical examination can be used to rule out other conditions, such as hypothyroidism, which are associated with chronic constipation. When indicated, laboratory tests can be ordered. A sensory examination and a careful neurologic assessment can rule out neurogenic causes, such as a spinal cord lesion. Chronic constipation has also been attributed to Crohn's disease (as a result of thrombosis and scarring of inflamed bowel), malnutrition, and disorders impairing voluntary muscle function (e.g., amyotonia congenita, infectious polyneuritis, and cerebral palsy). So-called ultrashort segment Hirschsprung's disease has been reported in some children. 15 In these cases anal manometry is said to demonstrate that rectal distention fails to initiate relaxation of the internal sphincter. Such findings, however, may be prone to misinterpretation, since they are not unique to aganglionosis. Chronic stretching of the bowel wall, in itself, may impair sphincter function even in youngsters with a functional megacolon. In such cases a biopsy may show an apparent decrease in ganglion cells. The definitive word on the existence of ultrashort segment Hirschsprung's disease is not in yet. Pediatricians therefore should be somewhat reluctant to make this diagnosis, especially if it leads to major surgical intervention. Abdominal and rectal examinations may help to estimate the degree of stool retention, but such findings are often deceptive. Many youngsters are laden with feces throughout the colon, but offer no indication of this on palpation or even rectal examination. Some appear to be "loaded" with soft stool. A plain x-ray film of the abdomen can be obtained and scored for the degree of retention. 2 This is helpful in the clinical evaluation, since some children demonstrate exclusively rectal constipation whereas others are encumbered with stool throughout the colon. Knowledge of the extent of retention can be essential for implementing and monitoring an appropriate regimen of catharsis (see section .on Treatment). A barium enema is seldom, if ever, necessary. Anal manometry has sometimes been employed to evaluate sphincter function. At present, however, its therapeutic implications are not clear-cut. It is used to diagnose Hirschsprung' s disease, but children with functional encopresis may show manometric abnormalities as noted. These findings generally will not change the approach to medical treatment. A rectal biopsy may be indicated when there are signs truly suggestive of a ganglionic megacolon. One can argue that a biopsy is appropriate when symptoms have not abated despite long-term optimal management. However, the yield, even in such cases, is low. Girls with encopresis commonly suffer from urinary tract infections because of ascending invasion secondary to perineal soiling. Therefore, it is good practice to include a urinalysis and culture in the initial evaluation of
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any female with fecal incontinence. Radiographic studies of the urinary tract are also indicated in long-standing cases, since some girls may harbor chronic pyelonephritis as a result of their encopresis: Obstructive urothropathies have been described in children of both sexes with chronic obstipation.16 These are likely to improve after restoration of normal bowel function.
ALLEVIATION Various approaches have been suggested for the management of children with encopresis. 5• 9• 17 Aims include the establishment of a regular bowel habit, reduced stool retention, and optimal neuromuscular bowel function, along with the alleviation of emotional scars. The medical aspects often are accomplished through retraining, combined with pharmacologic measures to promote complete evacuation. Table 2 summarizes one treatment approach. The medical therapy of encopresis can be enhanced greatly through the use of initial "demystification" and ongoing counseling. First, the youngster and parent should be assured that many other children have this problem. A child may need to know specifically that there are other youngsters in his or her town or school who are similarly afflicted. Such reassurance addresses the extreme isolation that parents and children may feel. It is helpful for a child to be informed that "other cool guys also have a messing problem." The child should be encouraged not to feel embarrassed or "on trial" in discussing the problem with the physician. The latter should explain that a problem with bowels is not all that different from a sore throat or a runny nose. The approach should be positive and nonaccusatory at all times. The physician should express admiration for the courage and even heroism of the child who always has to be on guard not to have the problem discovered by his friends. It often is helpful to use drawings to portray for the child and the parents the pathogenetic mechanism of stretched-out bowels that have lost their sensation and muscle tone. Figure 1 is an example of such illustrative material. The child is shown a cross-section of a normal intestine. Its function at carrying away waste is explained. The use of muscle to propel the material out of the body and the function of nerves in informing the child when he has to go to the bathroom can be stressed. The child is then told how, for some reason or other, some children do not empty themselves completely or often enough. At this point one might want to insert a plausible explanation for that particular child's retention. The child is then shown a cross-section of a intestine in which there is a growing accumulation of "rocks" or waste. It is explained that when the bowel becomes full of such material there is no place for the material to go; consequently, it stays around, gets very hard sometimes, and stretches out the big pipe. Such distention results in a thinning and weakening of the muscles. Therefore, there is not enough strength to push the rocks out, and more and more accumulate. When new soft waste is made, it tends to flow in the spaces around and between the rocks and come dripping out in one's underpants. Further, it should be pointed out that a stretched out intestine ends up with stretched
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Table 2. TREATMENTPHASE
Approach to Treatment*
TREATMENTPROGRAM
COMMENTS
Initial counseling
1. Education and "demystification" of the problem 2. Removal of blame 3. Establishment and explanation of treatment plan
Include drawings, review of colonic function, shared observation of x7rays; emphasize need for intestinal "muscle-building"
Initial catharsis Inpatient
1. High normal saline enemas (750 cc bid) 3 to 7 days 2. Biscodyl (Dulcolax) suppositories bid, 3 to 7 days 3. Use of bathroom for 15 minutes each meal
Patient admitted when: 1. retention is very severe 2. home compliance likely to be poor 3. parents prefer admission 4. parental administration of enemas is inadvisable psychologically
1. For moderate to severe retention, 3 or 4 cycles as follows: a. Day 1. Hypophosphate enemas (Fleet's adult) twice b. Day 2. Biscodyl (Dulcolax) suppositories twice c. Day 3. Biscodyl (Dulcolax) tablet once 2. For mild retention, senna or danthron; one tablet daily for 1 to 2 weeks.
1. Dosages or frequency may need alteration if child experiences excessive discomfort 2. Admission should be considered if there is inadequate yield
At home
Follow-up Abdominal X-ray to Confirm A!fequate Catharsis Maintenance
1. Child sits on toilet twice a day at same times each day for 10 minutes each time 2. Light mineral oil (at least 2 tablespoons) twice a day usually for at least 4 to 6 months 3. Multiple vitamins, 2 a day, between mineral oil doses 4. High roughage diet, usually bran cereal 5. In severe cases use of an oral laxative (senna or danthrone) for 2 to 3 weeks, then alternate days for 1 month (given between mineral oil doses)
1. A kitchen timer may be helpful 2. A chart with stars for sitting may be good for children under 7 3. Bathroom reading encouraged 4. Mineral oil may be put in juice or Coke or any other medium 5. Vitamins to compensate for alleged problems with absorption secondary to mineral oil 6. Diet should be applied, but not to the point of coercion
Follow-up
1. Visits every 4 to 10 weeks, depending on severity, need for support, compliance, and associated symptoms 2. Telephone availability to adjust doses when needed 3. In case ofrelapse: a. check compliance b. Use of oral laxative (e.g., Senokot) for 1 to 2 weeks c. adjust dosage of mineral oil 4. Counseling and/or referral for associated psychosocial and developmental issues
1. Duration of treatment program may be as long as 2 to 3 years or as short as 6 months 2. Signs of relapse: a. excessive oil leakage b. large caliber stools c. abdominal pain d. decreased frequency of defecation e. soiling 3. Physician should spend time alone with the child 4. In cases slow to respond, physician should sustain optimism: persistence cures almost all cases (eventually)
*Adapted from Pediatr. Rev., 2:285, 1981. All dosages and frequencies are for an average-sized 7 year old child. Appropriate adjustments should be made for smaller and larger patients.
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Figure 1. This diagrammatic representation is used in the "demystification" of children with encopresis. A poster-sized enlargement of this figure serves to represent visually normal intestinal musculature, its distention with "rocks" of body waste, the development of a megacolon with stretched out thin muscles and nerves, the beginning resolution of the problem, and, ultimately, the restoration of normal function. This teaching aid can help the clinician during initial counseling of the child and parents. An enlarged reproduction of this diagram can be obtained by writing to the author.
out nerves, which stop working, so a child no longer gets much warning or feeling that he or she needs to visit the bathroom. In other words, the waste just comes out, and the first time a child is aware of it is when it is already in the underpants-i.e., too late. It is also helpful to point out that some children get accustomed to messing their pants and even have trouble smelling their products. The demystification process, such as that described above, sets the stage for a nonaccusatory, advice-giving approach on the part of the physician. The pediatrician can set himself up as a "coach." The predominant theme from_ that point onward is the building of muscles to control bowels. The metaphor of muscle has significance for a school-aged child. It symbolizes growing up, acquiring autonomy, feeling effective, and being in social control. The demystification process should be witnessed by parents, although sometimes this creates anxiety or guilt. A parent who has been punishing a child for not coming in after an accident may feel upset at the realization that the child may not have felt it coming or even smelled it once it was there. The physician may need to reassure parents that such misunderstandings are common in this condition. The physician should explain that the treatment of the bowel disorder will depend largely on cleaning out the rocks from the intestine and then preventing new ones from forming over a long enough time period for the bowel to regain its width, feelings, and strength. The physician should em-
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phasize that children vary greatly in the amount of time needed for this restoration. Some respond within weeks, whereas others must have months or even years of treatment. Successful management usually requires a vigorous initial catharsis. This is particularly true in those children who have a functional megacolon with diffuse stool distribution as visualized by x-ray examination. Many treatment failures stem from an incomplete initial cleanout. An outpatient catharsis (see Table 2) may include four three-day cycles, beginning the first day with two adult-size Fleet enemas (given together), followed on the second day by a biscodayl (Dulolax) suppository and on the third day by a biscodayl tablet. In many cases four or five such cycles (i.e., 12 to 15 days) may be needed before a child is fully cleansed. A followup film of the abdomen after two to three weeks commonly is needed to establish either success or the need for an even more prolonged initial catharsis. In some cases, hospitalization is required for the initial cleanout. This is true if the stool retention and megacolon are extremely severe, such that more vigorous expurgation is required. Other criteria for admission include: a severely disturbed parent-child relationship (in which case giving enemas at home may be harmful), parents who feel they cannot manage this program themselves, or cases in which a period of separation would be helpful in establishing clearly for the child that incontinence is his problem. In any case, the initial catharsis is explained to the parents and the child as "a necessary evil." That is to say, one does not like to invade from below, but that approach is crucil=il in the short run, and, hopefully, all future treatments will enter through th~ mouth! Once the initial catharsis is successfully completed, a less invasive but persistent training routine is established. Included are regular visits to the toilet (whether or not the child feels the urge). Ordinarily he is required to sit twice a day, at the same times each day, for at least 10 minutes each time. A kitchen timer may be employed to document this. It is crucial that the child understand that such a routine constitutes training and muscle-building rather than punishment! In younger children, there can be some increased incentive through the use of a star-chart documenting use of the toilet and perhaps offering extra credit or prizes for particularly good results. The overall thrust is directed toward increasing regularity and bowel autonomy. Defecation can be facilitated with laxatives and/or stool softeners. Most commonly, light mineral oil is used at a starting dose of about two tablespoons twice a day (generally adequate for school-aged children). The dosage may be adjusted depending upon age and response. If mineral oil is used before or during the initial catharsis, it is likely to leak and produce a demoralizing mess. In general, mineral oil should not be used to "clean out" a child; its purpose is to help maintain good bowel function after the initial catharsis. Some children may prefer a commercial preparation of flavored mineral oil; in other cases, families can use their own judgment and add various appealing ingredients. Many children seem to tolerate mineral oil better if it is kept refrigerated. In more severe cases an oral laxative is also used. Senna (Senekot) or danthron (Modane) can be started at one tablet or its equivalent each day and then tapered to alternate days after several
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weeks. In most cases, after one or two months, the stool softener can be used without laxative therapy. The latter however should be reintroduced during periods of exacerbation. Increasing dietary fiber may be helpful; a heaping bowl of bran cereal each morning might suffice. However, parent-child combat over such intake must be discouraged. If the child despises the bran cereal, it should not be insisted upon. Treatment must continue for a prolonged period; training and medical management may require a minimum of six months in all but the mildest cases. Partially treated encopresis commonly results in humiliating exacerbations. There must be follow-up visits and telephone contacts to deal with the regulation of medication, with behavioral issues, and with reactions to relapses. In those instances in which pediatric efforts fail because of serious family psychopathology or even active parental sabotage, a psychiatric referral is indicated. However, the latter never should be a total replacement for pediatric management. Optimally, the two disciplines must work in concert to alleviate this condition.
RESISTANT CASES Some children have accidents despite good consistent management. At The Children's Hospital Medical Center in Boston, nearly 20 per cent of referred cases follow this course. 9 In encopresis, as in other functional complaints of childhood, the remission rate is high but so is the relapse rate. The pediatrician treating encopresis must recognize that the disorder may be chronic and recurrent and that it is taxing and frustrating to restore normal bowel function in some children. Pediatric perseverance is critical, as is resistance to the temptation to become accusatory when musculature does not respond properly. The physician, the parents, and the child easily become disenchanted with one another. Faced with the futility of treatment, many children become noncompliant. They may stand accused for not taking their medications or using the toilet at the designated hours. In such cases, however, the child .may be discouraged by the apparent ineffectiveness of intervention, feeling that it is safer not to try at all than to comply and fail. The physician needs to be sensitive to this all too common phenomenon. A strong trusting alliance with the child should be formed. All must understand that sometimes encopresis requires years of treatment to achieve a cure; no one needs to shoulder the blame for this. Parents are likely to need a considerable amount of support to coexist with a child who has encopresis. One needs to help shape their reactions to exacerbations. The child should not be chastized for messing his pants. On the other hand, he can be held accountable for noncompliance. Appropriate punishment can be given for not taking medicine or for refusing to visit the bathroom. The child should be encouraged to wash his own body, but should not be expected to launder soiled underpants. Mothers, fathers, sisters, brothers, and grandparents need to be educated, so that their comments will not be too painful and add unnecessarily to the child's humiliation. One may need to enlist the cooperation of the school. For example,
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some children benefit from access to a private bathroom in. the health room or principal's office. The teacher should be sensitive to the child's problem, allowing use of the bathroom whenever requested. In serious cases, when accidents occur in school, a change of clothing may need to be available. Confidentiality about the child's problem is of course crucial. Some children with resistant encopresis may have specific food intolerances. In particular, fatty foods and milk products ~ay aggravate underlying bowel dysfunction. In resistant cases, the child must receive help in "covering up" his accidents in public. A humanitarian excuse from physical education or from taking showers in gym class may be essential. The child may need to be very careful about where he sits on the bus if the ride home commonly induces an accident. In such cases it may be important to seek another means of transportation. By demonstrating sensitivity to these totally intolerable situations,. the physician can strengthen his alliance with and ease the burden of a child with encopresis. When the battle ends successfully, a very grateful patient walks away triumphant and even strengthened.
ENCOPRESIS AS A MODEL Encopresis offers an interesting model for behavioral pediatrics. In its pathophysiology, diverse forces intermingle in varying d~grees at predictable lite stages. Among these are endogenous or congenital predispositions, the effects of early experience, the impacts of nurturance, possible iatrogenic effects, developmental and maturational phenomena, issues of training and discipline, the impacts of school. The management of encopresis requires an eclectic approach which combines the role of the physician as a diagnostic formulator, a demystifier and educator, a pharmacotherapist, a counselor, a strong child advocate and co-conspirator, and a triage officer for further referral when needed. Like other disorders of function in children, encopresis can test and strain the doctor-patient interface as severely as it threatens parent-child interactions. The challenge is in sustaining the helping relationship, persevering, uncovering strengths in a struggling child and family, and ultimately making good on the implied promise not to give up or abandon the case until the problem that they came in for gets fixed.
REFERENCES 1. Anthony, E. J.: An experimental approach to the psychopathology of childhood: encopresis. Br. J. Med. Psycho!., 30:146, 1957. 2. Barr, R. G., Levine, M.D., and Wilkinson, R. H.: Occult stool retention: A clinical tool for its evaluation in school-aged children. Clin. Pediatr. 18:674, 1979. 3. Bellman, M.: Studies on encopresis. Acta Pediatr. Scand., 170 (Suppl): 1, 1966. 4. Coekin, M., and Gairdner, D.: Fecal incontinence in children, the physical factor. Br. Med. J., 2:1175, 1960. 5. Davidson, M., Kugler, M. M., and Bauer, C. H.: Diagnosis and management in children with severe and protracted constipation and obstipation. J. Pediatr., 62:261, 1963. 6. Easson, W. M.: Encopresis-psychogenic soiling. Can. Med. Assoc. J., 82:624, 1960. 7. Huschka, M.: The child's response to coercive toilet training. Psychosom. Med., 2:301, 1942. 8. Levine, M. D.: Children with encopresis: A descriptive analysis. Pediatrics, 56:412, 1975.
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9. Levine, M.D.: The schoolchild with encopresis. Pediatr. Rev., 2:285, 1981. 10. Levine, M. D., and Bakow, H.: Children with encopresis: a study of treatment outcome. Pediatrics, 58:845, 1976. 11. Levine, M.D., and Barr, R. G.: Encopresis evaluation system. The Children's Hospital Medical Center, 1980. 12. Levine, M. D., Mazonson, P., and Bakow, H.: Behavioral symptom substitution in children cured of encopresis. Am. J. Dis. Child., 134:663, 1980. 13. Olatawura, M. 0.: Encopresis, a review of 32 cases. Acta Paediatr. Scand., 62:358, 1973. 14. Pinkerton, P.: Psychogenic megacolon in children: The implications of bowel negativism. Arch. Dis. Child., 33:371, 1958. 15. Roy, C. C., Silverman, A., and Cozzetto, F. J.: Pediatric Clinical Gastroenterology. St. Louis, C. V. Mosby Co., 1979, p. 799. 16. Shopfner, C. E.: Urinary tract pathology associated with constipation. Radiology, 90:865, 1968. 17. Silber, D. L.: Encopresis, discussion of etiology and management. Clin. Pediatr., 8:225, 1969. Children's Hospital Medical Center 300 Longwood Avenue Boston, Massachusetts 02115
Encopresis: Its Potentiation, Evaluation, and Alleviation Melvin D. Levine, M.D.*
"When I first got to Groton I had led so sheltered a life and was so shy that I was afraid to ask where the bathroom was. Hard as it may be to believe, I did what had to be done in my pants or in the bushes. I suppose I was surrounded by foul smells. Holding back as long as I could, I started to suffer stomach pains. Not knowing the cause, school officials suspected homesickness (well, I was homesick; at home I knew where the bathrooms were) and asked my parents to take me home for a few days to ease my adjustment". JAMES RooSEVELT
My Parents: A Differing View
Children with encopresis lack control over their bowels, having forsaken or never gained this most primitive form of efficacy. Commonly, the adult world indicts them for their habit, so that affected children are apt to see themselves as culprits, as prime agents in a self-destructive process. Ironically, they usually are innocent. Children commonly acquire the problem as a result of various combinations of unforeseen circumstances, constitutional predispositions, unintentional practices, inappropriate situations, and misunderstandings. Encopresis is defined as the deposition of formed or semiformed stools in a child's underwear (or other unorthodox locations), after the age of four years on a regular basis. Children generally have their "accidents" late in the day (between 3:00 and 7:00 P.M.). 8
The Question of Subtypes A number of attempts have been made to classify types of encopresis. Some authors differentiate between primary (or continuous) and secondary (or discontinuous) forms. 6· 13 The former describes a clinical picture that has been present "since birth"; in other words, the child has never been trained. Secondary encopresis is said to be a condition of children who have been completely toilet trained and subsequently regress to incontinence. Other authors distinguish between encopresis and fecal soiling, based on the extent to which full bowel movements are passed. Such subtyping, how*Associate Professor of Pediatrics, Harvard Medical School; Chief, Division of General Pediatrics, The Children's Hospital Medical Center, Boston, Massachusetts Pediatric Clinics of North America-Vol. 29, No. 2, April 1982
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ever, may not conform to clinical experience, since in long-standing cases symptoms commonly fluctuate over time, varying in the degree and frequency of incontinence. The same child at different times may stain or soil, produce small rock-like masses or clog the plumbing, or intersperse some relatively normal movements. Traditional classifications based on onset may also be misleading, since a significant subgroup of younsters may fall somewhere between the primary and secondary groups, having been partially bowel trained.
THE CLINICAL PICTURE Encopresis has been said to occur in 1.5 per cent of second grade youngsters. 3 The ratio of boys to girls varies from study to study, but has been placed at 6 to 1. The disorder shows little or no preference for social class. There is no evidence that it is related to family size, ordinal position of the child in the family, or age of parents .I As noted, virtually all children with encopresis retain stools, at least intermittently.12 This proclivity may be subtle and clinically elusive. Vague historical documentation, along with a normal abdominal and rectal examination, may prompt the clinician to describe a child as having "encopresis without constipation." Frequently, in such cases, a plain x-ray film of the abdomen will expose considerable fecal retention. It is common for children to gradually develop "occult" constipation or stool retention that may be asymptomatic or manifest itself as recurrent abdominal pain. Some such youngsters, may, in fact, defecate every day, but produce bowel movements that are incomplete. Their stool retention may not be severe enough to alter physical findings. Some children have predominantly rectal constipation, so that palpation of the abdomen reveals little. A rectal examination in such cases also may be difficult to interpret. As symptoms progress, sensory feedback from the bowel becomes impaired. The rectal wall is stretched and unable to contract forcefully enough. There is increased water absorption from fecal material, leading to ever harder and larger feces. Painful defecation may ensue and even promote anal £issues or hemorrhoids. This labored unpleasant process results in further avoidance or economy of toilet use, thereby engendering increased obstipation. Soon the anal canal becomes stretched and foreshortened. The function of the external and internal sphincters is compromised, allowing the passage of soft feces and mucus around impactions. Paradoxical sphincteric function leads to maladpative alterations of normal defecation reflexes. Physiological pressure : volume relationships are often impaired, such that an increase in the bulk of material within the rectum results in reduced (rather than higher) pressure generation by voluntary and involuntary musculature. It is likely that as better techniques are developed to evaluate bowel motility, a variety of physiologic derangements (both acquired and congenital) will be found to cause or predispose to encopresis.
Associated Symptoms Children with encopresis show a wide range of symptoms. In addition to their incontinence, some suffer from recurrent abdominal pain. They tend
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to be youngsters with a fairly recent onset of stool retention and incontinence. Those with long-standing encopresis generally have acquired tolerance to colonic distention, and seldom complain of pain. The prevalence of enuresis in children with encopresis varies from study to study. In some instances, a distended rectum may result in diminished bladder capacity and some urinary "dribbling" during the day. Treatment of the stool retention frequently alleviates the urologic symptoms. In many respects, encopresis is a "mirror image" of enuresis. In the latter, nocturnal symptoms are far more common. Encopresis at night is relatively rare and seems to have a poor prognosis.
Impact on Life Style and Affect Few children with encopresis harbor the symptoms in isolation. 11 • 14 Preexisting, concomitant, or secondary maladaptive traits are commonly encountered. An inability to control defecation is, of course, humiliating. Affected youngsters live in constant fear of discovery, of exposure, of ruthless peer ridicule. Self-esteem declines, and social withdrawal, anxiety, depression, and extra-abdominal somatic symptoms may occur. Acting-out or sociopathic behaviors are not frequently found in children with encopresis; they are more likely to isolate themselves to varying degrees and show excessive dependency. Commonly, encopresis engenders conflict, accusatory crossfire, as parents, grandparents, neighbors, and professionals advance often contradictory theories about why the child soils. Family activities may be compromised out of fear that the affected child could mess himself in the car, at a friend's house, or in a restaurant. Siblings may hesitate to invite friends home because of offensive indoor odors. Children with encopresis frequently bear cruel nicknames invented by their siblings and peers. A variety of coping mechanisms may be appropriated to deal with this. In most cases, affected children are unwilling or reluctant to discuss such ridicule with adults. A unique feature of encopresis differentiates it from most other functional disorders; namely, youngsters so afflicted almost never have knowledge of any others. Parents also are likely to be unaware of its existence as a common childhood problem. In many cases, they attribute the condition to laziness or poor hygiene and are reluctant to bring it to the attention of a physician. Personal shame and cultural taboos also may cause a family to delay in seeking help. All too often children with encopresis are indicted by the adult world. They are admonished and told they mess to get attention or because they are lazy. A child may be condemned for not returning promptly from play to use the toilet, despite his pathetic and totally honest lament: "I didn't feel it coming." He may be charged with negligence for not changing foul-smelling undergarments after an accident. Parents may fail to recognize that the olfactory sensory apparatus accommodates to odors that are present incessantly, that people have limited awareness of their own body smells, and that consequently a child with chronic incontinence is insensitive to the offensive odor of his own products! In appreciating the agony of encopresis, one must be sensitive to a human condition in which a child may be ridiculed, shamed, or blamed for
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something he did not cause and over which he had had little, if any, control. Such an intolerable predicament may be the most painful concomitant of incontinence.
PATHOGENESIS: STAGES AND POTENTIATION The symptom of incontinence represents the end result of the interplay of multiple factors whose cumulative impact potentiates the condition. Three developmental periods are critical in the generation of encopresis (Table 1). Stage I (Early Experience and Predisposition) covers the first 2 years of life. Stage II (Training and Autonomy) includes a span from 2 to 5 years. Stage III (Extramural Function) encompasses early school years. As children pass through these stages, constitutional predispositions, circumstances of environment, and critical life events may converge to potentiate a functional bowel disorder. In all likelihood, a youngster with only one potentiator can overcome or bypass such susceptibility. Most children with encopresis, on the other hand, appear to harbor multiple potentiating factors, the existence of one or more seeming to increase vulnerability to others. The time of onset of bowel difficulties provides pathogenetic clues. At The Children's Hospital Medical Center, a standardized questionnaire and manual have been developed to help clinicians probe the sources and describe the manifestations of a child's encopresis.I0 The following is an elaboration of commonly encountered potentiating factors at the three developmental stages. A particular child may begin to show vulnerability at an early Table I.
Potentiation of Risk for Encopresis*
Stage I Potentiators. Infancy and Toddler Years Simple constipation Early colonic inertia Congenital anorectal problems Other anorectal conditions Parental overreaction Coercive medical interventions Stage II Potentiators. Training and Autonomy-2 to 5 Years Psychosocial stresses during training period Coercive or extreme permissive training Idiosyncratic toilet fears Painful or difficult defecation Stage III Potentiators. Extramural Function-Early School Years Avoidance of school bathrooms Prolonged or acute gastroenteritis Attention deficits with task impersistence ? Food intolerance, including lactase deficiency Frenetic life styles Psychosocial stresses *Children who ultimately develop encopresis are likely to have accumulated multiple risk factors on this list.
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age and thereby become susceptible to the later acquisition of further potentiating factors. On the other hand, some children may not show their susceptibility until Stage II or Stage III. Stage I. Early Experience and Predisposition Children whose past history suggests significant bowel dysfunction during infancy and the toddler years may be revealing a constitutional or congenital predisposition to encopresis. A condition of "early colonic inertia" has been described as an endogenous tendency toward immature or generally inefficient function. 4 The disorder is common. In some instances it may result from genetic factors, whereas in other cases it may take the form of simple functional constipation from other causes. Most often this is a transient phenomenon, one that becomes a potentiator of encopresis only in the presence of other negative forces. Some youngsters with encopresis have a history of imperforate anus or related congenital anomalies, for which they have undergone corrective surgical procedures. The later development of encopresis may result directly from anatomic alteration or, alternatively, from the psychological aftereffects of early intervention in this region. Other more minor medical problems also may engender infantile difficulties with defecation. Specific food intolerances may be associated with constipation. Ordinarily these problems are inconvenient but self-limited, but in some cases they may be the start of a pathologic chain reaction culminating in encopresis. When there is a constitutional predisposition, further potentiation of encopresis in this age group may be induced by parental overreaction, as extremes of grief or exultation surrounding defecation may engender excessive bowel preoccupation on the part of a developing child. Aggressive management may also lead to dysfunction: overindulgence in suppositories and enemas, digital manipulation, and other coercive offenses may create a socalled "anal stamp." As one author has observed: "The battle of the bowel seemingly won in the nursery is destined to be lost on the playing fields at school." 1 An infant or toddler may himself potentiate impaired function through voluntary withholding. Defecation starts to be perceived as a negative experie.nce; the child strains excessively during bowel movements. Such exertion occurs with the legs hyperextended, creating the impression of a struggle to defecate, but, in reality, the act is an effort to retain rather than expel. Fissures and other forms of perianal irritation may result from constipation and, in themselves, potentiate chronic bowel difficulty by futher encouraging withholding. The preventive implications of such early potentiators are clear. In particular, consistent, low-key, and nonaggressive management of simple bowel problems is likely to minimize potentiation of an underlying susceptibility to encopresis. Stage II. Training and Autonomy During the preschool years, children explore new frontiers of autonomy and independence. To a developing child, bowel training and the newly acquired control it offers represent a major forward step. To some vulnerable
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youngsters, however, approaches to the toilet are marred by fear, by exaggerated power struggles, and by fantasy. During this stage children who have demonstrated bowel vulnerability earlier in life (i.e., during Stage I) are the most likely to continue to accummulate potentiating factors. A child who has integrated negative associations with defecation may be predisposed to fear the toilet, as that receptacle comes to symbolize one further hazard surrounding the unpleasant process of elimination. Apprehension regarding the toilet may constitute an initial potentiator of dysfunction in a child who has no previous history of bowel problems. Some youngsters, when they are trained on a toilet seat, have difficulty performing a Valsalva maneuver with their feet suspended in air. They might be very grateful for the use of a bench, some telephone directories, or any other forms of foot support. In the absence of this, there may be a lingering fear of falling in and of being flushed down. In some cases a child is trained to use the toilet but continues to harbor irrational fears regarding it. There may be fantasies about commodes that overflow and flood the bathroom, about sea monsters that bite when one sits down, or about babies being born in toilet bowls! Some apprehension is normal; in certain children the fear is excessive and culminates in long-standing often unconscious avoidance of defecation. Some do not avoid the toilet totally, but spend as little time there as possible, ultimately developing a routine of incomplete defecation. The immediate result is obstipation followed later by encopresis. Reluctance to defecate in the toilet often may occur as a result of psychosocial stresses coinciding with training efforts. It has been reported that inappropriate training techniques (especially extremes of coercion or permissiveness) also induce avoidance. 7 During Stage II, it is possible that certain medical conditions, such as chronic diarrhea from any source, may induce negative associations with defecation and a consequent potentiation of bowel dysfunction. A variety of potentiators can act upon underlying toilet fears and improper training. Where there are parent-child conflicts over autonomy and dependency, latent bowel dysfunctions may be activated. In a family in which there are constant battles over feeding and/or sleeping, the bathroom can evolve into still another combat zone! It should be emphasized that these conflicts need not constitute evidence of serious family psychopathology. Frequently, they are the results of misunderstandings, misplaced child rearing priorities, and inappropriate advice. Once again, it is likely that anticipatory guidance and parent education can prevent many cases of encopresis.
Stage III. Extramural Function During the early elementary school years, children who have had other potentiating factors may be predisposed to encopresis. New stresses come into play. The most important of these is school. In particular, school bathrooms are a common potentiator of encopresis. A child who is accustomed to defecation each morning at home may enter school and observe that there are no doors in front of the toilets, or that the school lavatory is the theater for a varied program of humiliating scenerios. Such a youngster may become
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determined to withhold defecation until back in the private safety of his own home. By 3:00 P.M., however, he has lost the urge! After several months in this holding pattern, the child may be obstipated and show paradoxical or overflow incontinence. It is not unusual during this stage for children with previous potentiation to begin to have encopresis immediately following a prolonged medical illness such as gastroenteritis. In such instances, normal bowel rhythms may be disturbed, and the child may not be able to compensate. When encopresis is potentiated during the school years, a number of factors are likely to operate. The loss of rectal and anal sensation described earlier is a complicating factor, as is the diminution in colonic muscle tone. A child's own anxiety about the symptom, aggravated by external stresses and pressures, worsens the condition. Dietary indiscretions, such as excessive ingestion of milk or chocolates, tend to exacerbate the problem. Children with a predisposition to bowel dysfunction who also have attention deficits or hyperactivity are particularly prone to develop encopresis. Such youngsters are globally task impersistent. They seldom finish anything they start, and that includes defecation! Thus, day after day, they have incomplete bowel movements, they steadily become constipated, and they eventually are incontinent. A similar phenomenon may be encountered in some susceptible boys and girls whose encopresis is potentiated by a frenetic lifestyle. Thus, a child who is late getting up in the morning and skips defecation in order to catch the school bus may chronically withhold as a result, meeting a tight schedule with an equally tight sphincter! Once again, it is likely that such a youngster will be found to have other potentiating factors if he is to develop encopresis.
General Considerations A multifactorial model is needed to account for the symptom of encopresis. It is inappropriate and unfair to prejudge a child with this problem. Many youngsters whose life adjustment is perfectly normal in all other respects develop encopresis as a result of potentiating forces beyond their control and that of their parents. In other instances, encopresis may be one manifestation of a more generalized picture of maladjustment and psychosocial stress. It follows that each case needs to be individualized, and it should never be assumed that a child with bowel incontinence is "emotionally disturbed."
CLINICAL EVALUATION The assessment of a child with encopresis should include careful consideration of the staged potentiators elucidated above. In addition, it is helpful to survey the range of current clinical manifestations and the forms of past or present management. The following questions should be answered as part of such an assessment: 1. To which developmental stage can one trace the origins of this youngster's difficulty? To answer this, one should examine carefully the age of onset of bowel-related symptoms. Have such problems been present
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since early in life? Was the onset associated with training efforts? Has this child ever been fully trained? Did entry into school or some other critical life event or transition coincide with the first evidence of bowel dysfunction? Did this youngster have any medical treatment or condition that may have resulted in an early "anal stamp"? 1 What other potentiating factors have been present? 2. What is the child's current pattern of toilet use? Does he or she avoid the facility totally or even partially? Is such reluctance confined to certain specific sites (e.g., school)? Are bathroom visits only very brief? 3. What is the current severity and pattern of this child's incontinence? Is incontinence limited primarily to the afternoon and evening? Does incontinence occur daily and fairly consistently throughout the week or, alternatively, is it a sporadic symptom? Are the accidents full bowel movements, just smudges, or mostly stains? 4. What psychosocial conditions in the child's environment may be promoting or aggravating the symptom? Is there marital strife? Are there problems with a sibling? Have there been serious setbacks for this family? Are there indications of deprivation or abnormal patterns of nurturance? 5. Are there characteristics of this child that may be aggravating encopresis? Does the youngster appear to be significantly depressed? Does the child have social interactional difficulties? Is this a youngster who has significant attention deficits, such that task impersistence interferes with establishing a normal bowel routine? Are there associated learning disabilities? 6. What has been the toll of encopresis for this child? Has the youngster developed secondary maladaptive strategies? Has there been some secondary gain from the symptom that is likely to impair speedy resolution? What associated patterns of behavior have emerged-perhaps in response to the child's encopresis? 7. How have the child and family coped with the symptom? Have consistent measures been employed? Has the problem caused considerable disagreement and strife? Is there guilt and accusation associated with the problem? How does the child cover up the disorder? 8. What is the child's understanding of the problem? Why does she or he believe that bowel control has been lost or does not exist? How directly can the child confront and talk about it? . 9. Why do the parents feel that the child has encopresis? What do they believe are the underlying causes? The answers to these questions are helpful in establishing a therapeutic alliance and in understanding the plight of a child with encopresis. Treatment and counseling plans should derive from such information. A complete physical examination should serve to rule out pathologic causes of stool retention and overflow. It should be recognized, however, that in the school-aged child pathologic causes are extremely rare. The sceptre of Hirschsprung's disease frequently overshadows encopresis. Clinicians should be aware of the great difference between the two conditions. These are reviewed in detail elsewhere. 12 Children with encopresis generally are well-nourished and healthy during the school years. A child with Hirschsprung' s disease at this age is likely to appear wasted and chronically ill and to have had intermittent obstructive symptoms. Children with enco-
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presis often have a history of having passed very large bowel movements (sometimes plugging the plumbing); those with Hirschsprung's disease are more likely to produce thin, ribbony stools. Incontinence is the most prominent symptom in children with encopresis; in Hi~schsprung's disease heavy soiling is unusual. Children with encopresis may have acquired their bowel symptoms relatively late in life, whereas those with Hirschsprung's disease commonly present with serious bowel problems in early infancy. The physical examination can be used to rule out other conditions, such as hypothyroidism, which are associated with chronic constipation. When indicated, laboratory tests can be ordered. A sensory examination and a careful neurologic assessment can rule out neurogenic causes, such as a spinal cord lesion. Chronic constipation has also been attributed to Crohn's disease (as a result of thrombosis and scarring of inflamed bowel), malnutrition, and disorders impairing voluntary muscle function (e.g., amyotonia congenita, infectious polyneuritis, and cerebral palsy). So-called ultrashort segment Hirschsprung's disease has been reported in some children. 15 In these cases anal manometry is said to demonstrate that rectal distention fails to initiate relaxation of the internal sphincter. Such findings, however, may be prone to misinterpretation, since they are not unique to aganglionosis. Chronic stretching of the bowel wall, in itself, may impair sphincter function even in youngsters with a functional megacolon. In such cases a biopsy may show an apparent decrease in ganglion cells. The definitive word on the existence of ultrashort segment Hirschsprung's disease is not in yet. Pediatricians therefore should be somewhat reluctant to make this diagnosis, especially if it leads to major surgical intervention. Abdominal and rectal examinations may help to estimate the degree of stool retention, but such findings are often deceptive. Many youngsters are laden with feces throughout the colon, but offer no indication of this on palpation or even rectal examination. Some appear to be "loaded" with soft stool. A plain x-ray film of the abdomen can be obtained and scored for the degree of retention. 2 This is helpful in the clinical evaluation, since some children demonstrate exclusively rectal constipation whereas others are encumbered with stool throughout the colon. Knowledge of the extent of retention can be essential for implementing and monitoring an appropriate regimen of catharsis (see section .on Treatment). A barium enema is seldom, if ever, necessary. Anal manometry has sometimes been employed to evaluate sphincter function. At present, however, its therapeutic implications are not clear-cut. It is used to diagnose Hirschsprung' s disease, but children with functional encopresis may show manometric abnormalities as noted. These findings generally will not change the approach to medical treatment. A rectal biopsy may be indicated when there are signs truly suggestive of a ganglionic megacolon. One can argue that a biopsy is appropriate when symptoms have not abated despite long-term optimal management. However, the yield, even in such cases, is low. Girls with encopresis commonly suffer from urinary tract infections because of ascending invasion secondary to perineal soiling. Therefore, it is good practice to include a urinalysis and culture in the initial evaluation of
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any female with fecal incontinence. Radiographic studies of the urinary tract are also indicated in long-standing cases, since some girls may harbor chronic pyelonephritis as a result of their encopresis: Obstructive urothropathies have been described in children of both sexes with chronic obstipation.16 These are likely to improve after restoration of normal bowel function.
ALLEVIATION Various approaches have been suggested for the management of children with encopresis. 5• 9• 17 Aims include the establishment of a regular bowel habit, reduced stool retention, and optimal neuromuscular bowel function, along with the alleviation of emotional scars. The medical aspects often are accomplished through retraining, combined with pharmacologic measures to promote complete evacuation. Table 2 summarizes one treatment approach. The medical therapy of encopresis can be enhanced greatly through the use of initial "demystification" and ongoing counseling. First, the youngster and parent should be assured that many other children have this problem. A child may need to know specifically that there are other youngsters in his or her town or school who are similarly afflicted. Such reassurance addresses the extreme isolation that parents and children may feel. It is helpful for a child to be informed that "other cool guys also have a messing problem." The child should be encouraged not to feel embarrassed or "on trial" in discussing the problem with the physician. The latter should explain that a problem with bowels is not all that different from a sore throat or a runny nose. The approach should be positive and nonaccusatory at all times. The physician should express admiration for the courage and even heroism of the child who always has to be on guard not to have the problem discovered by his friends. It often is helpful to use drawings to portray for the child and the parents the pathogenetic mechanism of stretched-out bowels that have lost their sensation and muscle tone. Figure 1 is an example of such illustrative material. The child is shown a cross-section of a normal intestine. Its function at carrying away waste is explained. The use of muscle to propel the material out of the body and the function of nerves in informing the child when he has to go to the bathroom can be stressed. The child is then told how, for some reason or other, some children do not empty themselves completely or often enough. At this point one might want to insert a plausible explanation for that particular child's retention. The child is then shown a cross-section of a intestine in which there is a growing accumulation of "rocks" or waste. It is explained that when the bowel becomes full of such material there is no place for the material to go; consequently, it stays around, gets very hard sometimes, and stretches out the big pipe. Such distention results in a thinning and weakening of the muscles. Therefore, there is not enough strength to push the rocks out, and more and more accumulate. When new soft waste is made, it tends to flow in the spaces around and between the rocks and come dripping out in one's underpants. Further, it should be pointed out that a stretched out intestine ends up with stretched
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Table 2. TREATMENTPHASE
Approach to Treatment*
TREATMENTPROGRAM
COMMENTS
Initial counseling
1. Education and "demystification" of the problem 2. Removal of blame 3. Establishment and explanation of treatment plan
Include drawings, review of colonic function, shared observation of x7rays; emphasize need for intestinal "muscle-building"
Initial catharsis Inpatient
1. High normal saline enemas (750 cc bid) 3 to 7 days 2. Biscodyl (Dulcolax) suppositories bid, 3 to 7 days 3. Use of bathroom for 15 minutes each meal
Patient admitted when: 1. retention is very severe 2. home compliance likely to be poor 3. parents prefer admission 4. parental administration of enemas is inadvisable psychologically
1. For moderate to severe retention, 3 or 4 cycles as follows: a. Day 1. Hypophosphate enemas (Fleet's adult) twice b. Day 2. Biscodyl (Dulcolax) suppositories twice c. Day 3. Biscodyl (Dulcolax) tablet once 2. For mild retention, senna or danthron; one tablet daily for 1 to 2 weeks.
1. Dosages or frequency may need alteration if child experiences excessive discomfort 2. Admission should be considered if there is inadequate yield
At home
Follow-up Abdominal X-ray to Confirm A!fequate Catharsis Maintenance
1. Child sits on toilet twice a day at same times each day for 10 minutes each time 2. Light mineral oil (at least 2 tablespoons) twice a day usually for at least 4 to 6 months 3. Multiple vitamins, 2 a day, between mineral oil doses 4. High roughage diet, usually bran cereal 5. In severe cases use of an oral laxative (senna or danthrone) for 2 to 3 weeks, then alternate days for 1 month (given between mineral oil doses)
1. A kitchen timer may be helpful 2. A chart with stars for sitting may be good for children under 7 3. Bathroom reading encouraged 4. Mineral oil may be put in juice or Coke or any other medium 5. Vitamins to compensate for alleged problems with absorption secondary to mineral oil 6. Diet should be applied, but not to the point of coercion
Follow-up
1. Visits every 4 to 10 weeks, depending on severity, need for support, compliance, and associated symptoms 2. Telephone availability to adjust doses when needed 3. In case ofrelapse: a. check compliance b. Use of oral laxative (e.g., Senokot) for 1 to 2 weeks c. adjust dosage of mineral oil 4. Counseling and/or referral for associated psychosocial and developmental issues
1. Duration of treatment program may be as long as 2 to 3 years or as short as 6 months 2. Signs of relapse: a. excessive oil leakage b. large caliber stools c. abdominal pain d. decreased frequency of defecation e. soiling 3. Physician should spend time alone with the child 4. In cases slow to respond, physician should sustain optimism: persistence cures almost all cases (eventually)
*Adapted from Pediatr. Rev., 2:285, 1981. All dosages and frequencies are for an average-sized 7 year old child. Appropriate adjustments should be made for smaller and larger patients.
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Figure 1. This diagrammatic representation is used in the "demystification" of children with encopresis. A poster-sized enlargement of this figure serves to represent visually normal intestinal musculature, its distention with "rocks" of body waste, the development of a megacolon with stretched out thin muscles and nerves, the beginning resolution of the problem, and, ultimately, the restoration of normal function. This teaching aid can help the clinician during initial counseling of the child and parents. An enlarged reproduction of this diagram can be obtained by writing to the author.
out nerves, which stop working, so a child no longer gets much warning or feeling that he or she needs to visit the bathroom. In other words, the waste just comes out, and the first time a child is aware of it is when it is already in the underpants-i.e., too late. It is also helpful to point out that some children get accustomed to messing their pants and even have trouble smelling their products. The demystification process, such as that described above, sets the stage for a nonaccusatory, advice-giving approach on the part of the physician. The pediatrician can set himself up as a "coach." The predominant theme from_ that point onward is the building of muscles to control bowels. The metaphor of muscle has significance for a school-aged child. It symbolizes growing up, acquiring autonomy, feeling effective, and being in social control. The demystification process should be witnessed by parents, although sometimes this creates anxiety or guilt. A parent who has been punishing a child for not coming in after an accident may feel upset at the realization that the child may not have felt it coming or even smelled it once it was there. The physician may need to reassure parents that such misunderstandings are common in this condition. The physician should explain that the treatment of the bowel disorder will depend largely on cleaning out the rocks from the intestine and then preventing new ones from forming over a long enough time period for the bowel to regain its width, feelings, and strength. The physician should em-
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phasize that children vary greatly in the amount of time needed for this restoration. Some respond within weeks, whereas others must have months or even years of treatment. Successful management usually requires a vigorous initial catharsis. This is particularly true in those children who have a functional megacolon with diffuse stool distribution as visualized by x-ray examination. Many treatment failures stem from an incomplete initial cleanout. An outpatient catharsis (see Table 2) may include four three-day cycles, beginning the first day with two adult-size Fleet enemas (given together), followed on the second day by a biscodayl (Dulolax) suppository and on the third day by a biscodayl tablet. In many cases four or five such cycles (i.e., 12 to 15 days) may be needed before a child is fully cleansed. A followup film of the abdomen after two to three weeks commonly is needed to establish either success or the need for an even more prolonged initial catharsis. In some cases, hospitalization is required for the initial cleanout. This is true if the stool retention and megacolon are extremely severe, such that more vigorous expurgation is required. Other criteria for admission include: a severely disturbed parent-child relationship (in which case giving enemas at home may be harmful), parents who feel they cannot manage this program themselves, or cases in which a period of separation would be helpful in establishing clearly for the child that incontinence is his problem. In any case, the initial catharsis is explained to the parents and the child as "a necessary evil." That is to say, one does not like to invade from below, but that approach is crucil=il in the short run, and, hopefully, all future treatments will enter through th~ mouth! Once the initial catharsis is successfully completed, a less invasive but persistent training routine is established. Included are regular visits to the toilet (whether or not the child feels the urge). Ordinarily he is required to sit twice a day, at the same times each day, for at least 10 minutes each time. A kitchen timer may be employed to document this. It is crucial that the child understand that such a routine constitutes training and muscle-building rather than punishment! In younger children, there can be some increased incentive through the use of a star-chart documenting use of the toilet and perhaps offering extra credit or prizes for particularly good results. The overall thrust is directed toward increasing regularity and bowel autonomy. Defecation can be facilitated with laxatives and/or stool softeners. Most commonly, light mineral oil is used at a starting dose of about two tablespoons twice a day (generally adequate for school-aged children). The dosage may be adjusted depending upon age and response. If mineral oil is used before or during the initial catharsis, it is likely to leak and produce a demoralizing mess. In general, mineral oil should not be used to "clean out" a child; its purpose is to help maintain good bowel function after the initial catharsis. Some children may prefer a commercial preparation of flavored mineral oil; in other cases, families can use their own judgment and add various appealing ingredients. Many children seem to tolerate mineral oil better if it is kept refrigerated. In more severe cases an oral laxative is also used. Senna (Senekot) or danthron (Modane) can be started at one tablet or its equivalent each day and then tapered to alternate days after several
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weeks. In most cases, after one or two months, the stool softener can be used without laxative therapy. The latter however should be reintroduced during periods of exacerbation. Increasing dietary fiber may be helpful; a heaping bowl of bran cereal each morning might suffice. However, parent-child combat over such intake must be discouraged. If the child despises the bran cereal, it should not be insisted upon. Treatment must continue for a prolonged period; training and medical management may require a minimum of six months in all but the mildest cases. Partially treated encopresis commonly results in humiliating exacerbations. There must be follow-up visits and telephone contacts to deal with the regulation of medication, with behavioral issues, and with reactions to relapses. In those instances in which pediatric efforts fail because of serious family psychopathology or even active parental sabotage, a psychiatric referral is indicated. However, the latter never should be a total replacement for pediatric management. Optimally, the two disciplines must work in concert to alleviate this condition.
RESISTANT CASES Some children have accidents despite good consistent management. At The Children's Hospital Medical Center in Boston, nearly 20 per cent of referred cases follow this course. 9 In encopresis, as in other functional complaints of childhood, the remission rate is high but so is the relapse rate. The pediatrician treating encopresis must recognize that the disorder may be chronic and recurrent and that it is taxing and frustrating to restore normal bowel function in some children. Pediatric perseverance is critical, as is resistance to the temptation to become accusatory when musculature does not respond properly. The physician, the parents, and the child easily become disenchanted with one another. Faced with the futility of treatment, many children become noncompliant. They may stand accused for not taking their medications or using the toilet at the designated hours. In such cases, however, the child .may be discouraged by the apparent ineffectiveness of intervention, feeling that it is safer not to try at all than to comply and fail. The physician needs to be sensitive to this all too common phenomenon. A strong trusting alliance with the child should be formed. All must understand that sometimes encopresis requires years of treatment to achieve a cure; no one needs to shoulder the blame for this. Parents are likely to need a considerable amount of support to coexist with a child who has encopresis. One needs to help shape their reactions to exacerbations. The child should not be chastized for messing his pants. On the other hand, he can be held accountable for noncompliance. Appropriate punishment can be given for not taking medicine or for refusing to visit the bathroom. The child should be encouraged to wash his own body, but should not be expected to launder soiled underpants. Mothers, fathers, sisters, brothers, and grandparents need to be educated, so that their comments will not be too painful and add unnecessarily to the child's humiliation. One may need to enlist the cooperation of the school. For example,
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some children benefit from access to a private bathroom in. the health room or principal's office. The teacher should be sensitive to the child's problem, allowing use of the bathroom whenever requested. In serious cases, when accidents occur in school, a change of clothing may need to be available. Confidentiality about the child's problem is of course crucial. Some children with resistant encopresis may have specific food intolerances. In particular, fatty foods and milk products ~ay aggravate underlying bowel dysfunction. In resistant cases, the child must receive help in "covering up" his accidents in public. A humanitarian excuse from physical education or from taking showers in gym class may be essential. The child may need to be very careful about where he sits on the bus if the ride home commonly induces an accident. In such cases it may be important to seek another means of transportation. By demonstrating sensitivity to these totally intolerable situations,. the physician can strengthen his alliance with and ease the burden of a child with encopresis. When the battle ends successfully, a very grateful patient walks away triumphant and even strengthened.
ENCOPRESIS AS A MODEL Encopresis offers an interesting model for behavioral pediatrics. In its pathophysiology, diverse forces intermingle in varying d~grees at predictable lite stages. Among these are endogenous or congenital predispositions, the effects of early experience, the impacts of nurturance, possible iatrogenic effects, developmental and maturational phenomena, issues of training and discipline, the impacts of school. The management of encopresis requires an eclectic approach which combines the role of the physician as a diagnostic formulator, a demystifier and educator, a pharmacotherapist, a counselor, a strong child advocate and co-conspirator, and a triage officer for further referral when needed. Like other disorders of function in children, encopresis can test and strain the doctor-patient interface as severely as it threatens parent-child interactions. The challenge is in sustaining the helping relationship, persevering, uncovering strengths in a struggling child and family, and ultimately making good on the implied promise not to give up or abandon the case until the problem that they came in for gets fixed.
REFERENCES 1. Anthony, E. J.: An experimental approach to the psychopathology of childhood: encopresis. Br. J. Med. Psycho!., 30:146, 1957. 2. Barr, R. G., Levine, M.D., and Wilkinson, R. H.: Occult stool retention: A clinical tool for its evaluation in school-aged children. Clin. Pediatr. 18:674, 1979. 3. Bellman, M.: Studies on encopresis. Acta Pediatr. Scand., 170 (Suppl): 1, 1966. 4. Coekin, M., and Gairdner, D.: Fecal incontinence in children, the physical factor. Br. Med. J., 2:1175, 1960. 5. Davidson, M., Kugler, M. M., and Bauer, C. H.: Diagnosis and management in children with severe and protracted constipation and obstipation. J. Pediatr., 62:261, 1963. 6. Easson, W. M.: Encopresis-psychogenic soiling. Can. Med. Assoc. J., 82:624, 1960. 7. Huschka, M.: The child's response to coercive toilet training. Psychosom. Med., 2:301, 1942. 8. Levine, M. D.: Children with encopresis: A descriptive analysis. Pediatrics, 56:412, 1975.
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9. Levine, M.D.: The schoolchild with encopresis. Pediatr. Rev., 2:285, 1981. 10. Levine, M. D., and Bakow, H.: Children with encopresis: a study of treatment outcome. Pediatrics, 58:845, 1976. 11. Levine, M.D., and Barr, R. G.: Encopresis evaluation system. The Children's Hospital Medical Center, 1980. 12. Levine, M. D., Mazonson, P., and Bakow, H.: Behavioral symptom substitution in children cured of encopresis. Am. J. Dis. Child., 134:663, 1980. 13. Olatawura, M. 0.: Encopresis, a review of 32 cases. Acta Paediatr. Scand., 62:358, 1973. 14. Pinkerton, P.: Psychogenic megacolon in children: The implications of bowel negativism. Arch. Dis. Child., 33:371, 1958. 15. Roy, C. C., Silverman, A., and Cozzetto, F. J.: Pediatric Clinical Gastroenterology. St. Louis, C. V. Mosby Co., 1979, p. 799. 16. Shopfner, C. E.: Urinary tract pathology associated with constipation. Radiology, 90:865, 1968. 17. Silber, D. L.: Encopresis, discussion of etiology and management. Clin. Pediatr., 8:225, 1969. Children's Hospital Medical Center 300 Longwood Avenue Boston, Massachusetts 02115