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Hospital treatment of the encopretic child
IRVING C. RINGDAHL, M.D.
Hospital treatment of the encopretic child ABSTRACT: Encopresis, or fecal soiling, is a troublesome disorder
of children that can be quite difficult to manage. It is often a symptom of a disturbed family. This article describes a successful treatment method that is carried out in a hospital setting. In the author's experience, effective treatment requires a combination of behavior modification techniques with individual, group, occupational, and family therapy, in a hospital setting. Encopresis is an act of repeated, involuntary fecal soiling in the absence of physical illness.' Typically, an encopretic child is a boy between 5 and 7 years old. He postpones or refuses using the toilet and instead defecates small amounts of stool in his pants. Not infrequently, the child hides his soiled garments, trying to escape detection by his mother. Persistent fecal soiling is a most offensive disorder and one that child psychiatrists consider difficult to manage. It is a complex problem that involves much more than better toilet training. Unless there is evidence of organic disease, this
condition is usually symptomatic of serious psychopathology in both the affected child and his family.2-4 Encopretic children are most often immature and passive, and display a great deal of underlying anger. When first seen by a physician, they are usually guarded, sullen, and reluctant to disclose any information relating to their soiling habit. The families of these children often have serious problems. An unexpectedly high percentage of parents are divorced or separated. If the parents are living together, severe marital problems are 'usually evident. Characteristically, the mothers are hostile, domineer-
, Dr. Ringdahl is assistant professor ofchildpsychiatry at the University ofArkansasfor Medical Sciences. Reprint requests to him there, 4301 West Markham, Little Rock, AR 72201. JANUARY 1980' VOL 21' NO 1
ing, and intrusive into the child's life. The fathers, in contrast, are passive and tend to take a stance remote from family involvement. Some child psychiatrists suggest that encopretic children may engage in soiling as a means of gaining attention or in some cases as vengeance against the parents. Where the father is absent from the home, the symptom often occurs within the context of a hostile dependency relationship with the mother. Differential diagnosis
A careful history and appropriate diagnostic procedures are necessary to exclude other bowel habit disorders. s Paradoxical obstipation can be confused with true encopresis. Children with paradoxical obstipation repeatedly postpone defecation; a large, hard fecal lump forms in the rectum and results in involuntary leakage. Hirschsprung's disease can be distinguished from true encopresis by the presence of persistent con. stipation, evident shortly after birth. Fecal incontinence is uncom6S
Encopresis
mon in Hirschsprung's, and a history of volvulus is often obtained. X-ray studies and a rectal biopsy will verify the diagnosis. Traumata and deformities of the anus may produce leakage of fecal material. An anorectal examination will usually determine the presence of disease in the area. In addition, .injury to the distal spinal cord or tumors in this area may produce fecal soiling. However, urinary incontinence usually presents a problem as well when nerve disturbances are present in the region of the cauda equina. Management approaches Many child psychiatrists consider the management of encopresis difficult because adverse psychological factors including, typically, a hostile power struggle, are quite difficult to control. Therefore, recalcitrant children need to be separated from their parents and placed in a hospital setting where the various contingency factors can be controlled more effectively. Within the hospital a variety of treatment modalities-including behavior modification techniques, individual therapy, group therapy, occupational therapy, and family therapy-are usually available to the physician. Since a child's soiling problem often is symptomatic of family dysfunction, it is extremely important to involve the parents in therapy during the child's hospitalization. Hoag and associates 3 relate the successful treatment of encopresis to resolution of family conflicts. Other techniques may also be useful. For example, certain children exhibit prominent depression symptomatology; adding a tranquilizing or antidepressant medication to the treatment regimen may
prove helpful to them. Davidson and associates 6 describe a method to control overflow fecal soiling. In this regimen, one or two pairs of hypertonic phosphate enemas are initially administered to completely remove fecal material from the child's rectum. After the enemas, sufficient quantities of mineral oil are given orally twice a day and the child is toileted at a regular time each day for 15 minutes in an attempt to establish a normal bowel habit routine. In addition, the child is encouraged to use the commode as often as is necessary at other times of the day. Some physicians have modified this approach to better meet the individual requirements of the child. Review of cases To gain a better understanding of some of the features seen in encopretic cases, we undertook a study of all children who were hospitalized on the Psychiatric Children's Unit at the University of Arkansas Medical Center from 1972 to 1978 with a primary diagnosis of encopresis. During this period, 13 children were admitted for treatment of this disorder, 12 of whom were boys. While encopresis is known to occur more commonly among boys, the male proportion in our review was considerably higher than that reported by Bellman,S who found the male:female ratio to be 3.4: 1. The incidence of encopresis was also higher in our study; of395 children admitted to the Psychiatric Children's Unit, 3.3% were diagnosed as having encopresis. The overall incidence reported in other studies is
1.5%.5 Differences were found among the children in our study in several respects. Six were last-born, while only two were first-born. The onset
of encopresis apparently correlated with the birth of a younger sibling in two of the children. Encopresis followed a painful cystoscopic procedure in one other child, and in another was felt to be associated with a spinal cord injury at the age of 20 months. Five children had never been adequately toilet trained and were considered to be primary soilers. The remaining eight secondary soilers had varied age at onset from 4 to 9 years, with a mean of 6.2 years. The duration of symptoms prior to hospitalization varied from one to four years. Four children had an accompanying nocturnal enuresis; three of these were primary soilers. Moderately severe behavior problems such as aggression, destructiveness, lying, and stealing were evident in six boys, two of whom had also set fires. At least three children displayed significant depression symptomatology, and hyperkinesis was evident in two. Toilet training had been completed before the third year in all children who suffered from secondary encopresis. Family pathology Without exception, the children's families displayed varying degrees of psychopathology. Divorce had broken ten of the 13 families. The other families were intact but living under conditions of severe marital discord; the mothers were the dominant figures in the home and the fathers assumed a more passive role. In two of these families, numerous separations had taken place. Hostility, either overt or covert, was evident in roughly 75% of the mothers. Four mothers showed marked overt hostility and made therapy difficult. Several mothers appeared to be clinically depressed. (continued)
JANUARY 1980· VOL 21 • NO 1
69
Encopresis
Children of divorced families in every instance lived primarily with the mother, and contacts with the natural father were brief, sporadic, or nonexistent. None of the 13 fathers had been involved with the children in significant or meaningful ways. Not unexpectedly, a child's soiling generally worsened with increased turmoil within the home. In most cases, soiling occurred primarily at home in close proximity to the mother. Often, symptoms were exacerbated when a divorced father returned to visit his child in the home. All children in the study had undergone prior treatment for encopresis, either by a family physician or pediatrician or at the local community mental health center. Various treatment methods had been tried without significant therapeutic effects. The parents had utilized a number of punitive as well as nonpunitive approaches to get their child to stop soiling; these were all unsuccessful. All 13 encopretic children had a strong need to deny their symptom. Several seemed unaware that they were soiling their clothing. Some hid their soiled garments in various places during the initial period of hospitalization in order to escape detection. When confronted with this by the nursing staff, they strongly denied any involvement. One child actually complained that while he was asleep his undergarments were stolen by his roommate, who then soiled them and hid them in the closet. Intelligence No child in the study was mentally retarded. Eight had IQ scores that fell within the normal range, whereas five had scores in the superior range. The one child who 70
remained persistently encopretic despite our best therapeutic efforts had a full-scale IQ of 146. Academic performance was commensurate with the child's intellectual capabilities in most cases. Those children who did poorly academically tended to be the more depressed members of the group. Hollingshead's Index of Social Position was used to measure social class status. One child came from a class III home, eight came from class IV homes, and four children from class V homes. Multimodal treatment A multimodal therapeutic approach similar to that described by Halpern 7 was used in the hospital. Behavior modification strategies, using primarily positive reinforcement techniques, were found to be very effective in controlling most children's soiling habits. Weekly group therapy sessions were carried out, in which each child was encouraged to talk about "my problem." Individual therapy using a combined supportive and insight approach proved helpful in most cases. Occupational therapy was found to be a useful adjunct in improving the self-esteem of children with a poor self-image. Finger painting and molding clay, using brown colors, provided a healthy outlet for those children who displayed tendencies toward being "messy." Family therapy and parental counseling were an integral part of treatment, since in the majority of cases soiling was considered symptomatic of a disturbed, dysfunctional family. A strong correlation was found between the continued cessation of a child's encopretic habit and resolution of family conflicts. A modification of Davidson's
method was utilized, primarily in those children whose encopresis was long-standing and in whom toilet training had never been adequately achieved. Following the administration of enemas, these children were initially given appropriate doses of milk of magnesia at bedtime; this laxative was continued throughout their hospitalization. All were required to go to the toilet immediately after breakfast for the purpose of defecating. The requirement of regular toilet attendance proved to be extremely help_ ful in getting the children to establish a normal bowel routine. The following case illustrates Our approach to the treatment of the encopretic child. Case report A 6-year-old boy, the youngest of three children, had been encopretic for two years. After the onset of his encopresis, he had undergone extensive diagnostic studies by a local pediatrician, and no physical basis was found for his problem. The parents had tried both punitive and nonpunitive measures in an attempt to control the soiling, but none had been successful. He was described by his parents as a nervous, fearful child who caused no discipline problem at home or school. Early history was unremarkable. The parents, in their mid305, held managerial positions in separate organizations. Marital discord had increased significantly over the preceding several years. The mother, previously married and divorced, was an aggressive, somewhat hostile individual and the dominant figure in the home. The father was passive by nature, but expressed resentment over the domestic responsibilities thrust upon him by his wife and the role reversal that had taken place in the home. During his free time, he tended to avoid his family. When the child was admitted to the
PSYCHOSOMATICS
Children's Psychiatric Service, he displayed shyness, mild withdrawal behavior, passivity, and difficulty expressing anger. Physical examination and routine laboratory studies were normal. A psychological evaluation revealed a full scale IQ score of 102 on the Wechsler Intelligence Scale for Children. His educational achievement scores were at grade level. No perceptual-motor deficits were evident in an occupational therapy assessment of the child. To promote soil-free periods, behavior modification techniques were utilized. Positive reinforcers consisted of opportunities to participate in those activities that were of value to the child. When soiling occurred, he was required to spend time washing his dirty clothing during his valued activity periods. He soiled two or three times during his first week'in the hospital, but thereafter did not soil again until his first weekend home visit. After his second visit with his parents, his soiling ceased altogether. Other therapeutic modalities included individual psychotherapy, group therapy, occupational therapy, and recreational therapy. During the various therapy sessions, the child was encouraged to express his feelings and become more assertive. In addition, he attended the inpatient school on a daily basis. As time progressed, he began to interact more with his peers. The entire family was seen weekly for family therapy. In these sessions, efforts were directed toward resolving some of the parents' long-standing differences. The mother was encouraged to be less assertive in the home, and the father was directed to spend more time with the child in a meaningful, constructive manner. In time, the mother became less of a dominant force in the family and assumed a different role in the home. During the family therapy sessions, the child and his siblings were encouraged to express their feelings regarding family problems. After six
JANUARY 1980· VOL 21 • NO 1
weeks, the child had reached maximal hospital benefit and was discharged. Subsequent family therapy sessions revealed continued freedom from encopresis as well as improved family functioning.
Treatment results The mean length of hospitalization for the 13 children was 26.7 days, with a range of IS to 52 days. The eight children with secondary encopresis discontinued their soiling during the first week ofhospitalization. The only girl in the study did not soil at any time while in the hospital. In retrospect, hers may not have been a true case of encopresis, as her soiling at home was related to a fearful avoidance of an ou tdoor toilet. Two children stopped soiling by the end of the second week. Once a proper toilet regimen was established, the child with the old spinal cord injury ceased his soiling during the third week of hospitalization. One child continued to soil throughout his hospitalization; however, his frequency of soiling lessened from several times a day to once or twice a week by the time he was discharged from the hospital. The only failure in the group was a child whose mother refused to cooperate with the therapeutic regimen. One child, whose soiling ceased during the first week of hospitalization, subsequently became enuretic. The enuresis was brought under control following institution of imipramine. Also, several children resumed soiling during their first weekend visit home; however, this soiling quickly abated after a return to the hospital setting. Two children who were successfully treated for their encopresis experienced an exacerbation of
their symptoms approximately a year later. In both cases, recurrence was related to severe conflict between the divorced parents fighting to gain custody of the child. The soiling quickly ceased when the children were rehospitalized. Once the children were discharged from the hospital and placed in suitable foster homes, they continued to remain symptom free. Conclusion The encopretic children in this study were primarily boys 'of average to above-average intelligence. All came from disturbed families; divorce had taken place in 10 of the 13 families. In roughly 75% of the cases, the mothers were viewed as being hostile; several were depressed. Separating the encopretic children from their families by placing them in a highly therapeutic hospital setting proved an effective method of treatment. The majority of children overcame their encopretic habit and responded to a multimodal therapeutic approach within the hospital with concurrent family therapy. At the same time, family functioning improved. REFERENCES 1. Kanner L: Child Psychiatry, ed 2. Springfield. III, Charles C Thomas. 1953. 2. Bemporad JR, Pfeifer eM, Gibbs L. et al: Characteristics of encopretic patients and their families. J Am Acad Child Psychiafry 10 272· 292,1971. 3. Hoag JM. Noriss NG, Himeno ET. el al: The encopretic child and his family. J Am Acad Child Psychiatry 10.242·256, 1971. 4. Anthony EJ: An experimental approach to the psychopathology of childhood encopresis. Sr J Meet Psychol30:14f>.175, 1957. 5. Bellman J: Studies in encopresis. Acta Paediatr Scand 170 (suppl):1.151, 1966. 6. Davidson M, Kugler MM, Baver CH: Diagnosis and management In children with severe and protracted constipation and obstipalion. J Pe· diatr 62:261·275, 1963. 7. Halpern WI: The treatment of encopretic chilo dren. JAm Acad Child Psychiatry 16:478·499. 1977.
71
Hospital treatment of the encopretic child ABSTRACT: Encopresis, or fecal soiling, is a troublesome disorder
of children that can be quite difficult to manage. It is often a symptom of a disturbed family. This article describes a successful treatment method that is carried out in a hospital setting. In the author's experience, effective treatment requires a combination of behavior modification techniques with individual, group, occupational, and family therapy, in a hospital setting. Encopresis is an act of repeated, involuntary fecal soiling in the absence of physical illness.' Typically, an encopretic child is a boy between 5 and 7 years old. He postpones or refuses using the toilet and instead defecates small amounts of stool in his pants. Not infrequently, the child hides his soiled garments, trying to escape detection by his mother. Persistent fecal soiling is a most offensive disorder and one that child psychiatrists consider difficult to manage. It is a complex problem that involves much more than better toilet training. Unless there is evidence of organic disease, this
condition is usually symptomatic of serious psychopathology in both the affected child and his family.2-4 Encopretic children are most often immature and passive, and display a great deal of underlying anger. When first seen by a physician, they are usually guarded, sullen, and reluctant to disclose any information relating to their soiling habit. The families of these children often have serious problems. An unexpectedly high percentage of parents are divorced or separated. If the parents are living together, severe marital problems are 'usually evident. Characteristically, the mothers are hostile, domineer-
, Dr. Ringdahl is assistant professor ofchildpsychiatry at the University ofArkansasfor Medical Sciences. Reprint requests to him there, 4301 West Markham, Little Rock, AR 72201. JANUARY 1980' VOL 21' NO 1
ing, and intrusive into the child's life. The fathers, in contrast, are passive and tend to take a stance remote from family involvement. Some child psychiatrists suggest that encopretic children may engage in soiling as a means of gaining attention or in some cases as vengeance against the parents. Where the father is absent from the home, the symptom often occurs within the context of a hostile dependency relationship with the mother. Differential diagnosis
A careful history and appropriate diagnostic procedures are necessary to exclude other bowel habit disorders. s Paradoxical obstipation can be confused with true encopresis. Children with paradoxical obstipation repeatedly postpone defecation; a large, hard fecal lump forms in the rectum and results in involuntary leakage. Hirschsprung's disease can be distinguished from true encopresis by the presence of persistent con. stipation, evident shortly after birth. Fecal incontinence is uncom6S
Encopresis
mon in Hirschsprung's, and a history of volvulus is often obtained. X-ray studies and a rectal biopsy will verify the diagnosis. Traumata and deformities of the anus may produce leakage of fecal material. An anorectal examination will usually determine the presence of disease in the area. In addition, .injury to the distal spinal cord or tumors in this area may produce fecal soiling. However, urinary incontinence usually presents a problem as well when nerve disturbances are present in the region of the cauda equina. Management approaches Many child psychiatrists consider the management of encopresis difficult because adverse psychological factors including, typically, a hostile power struggle, are quite difficult to control. Therefore, recalcitrant children need to be separated from their parents and placed in a hospital setting where the various contingency factors can be controlled more effectively. Within the hospital a variety of treatment modalities-including behavior modification techniques, individual therapy, group therapy, occupational therapy, and family therapy-are usually available to the physician. Since a child's soiling problem often is symptomatic of family dysfunction, it is extremely important to involve the parents in therapy during the child's hospitalization. Hoag and associates 3 relate the successful treatment of encopresis to resolution of family conflicts. Other techniques may also be useful. For example, certain children exhibit prominent depression symptomatology; adding a tranquilizing or antidepressant medication to the treatment regimen may
prove helpful to them. Davidson and associates 6 describe a method to control overflow fecal soiling. In this regimen, one or two pairs of hypertonic phosphate enemas are initially administered to completely remove fecal material from the child's rectum. After the enemas, sufficient quantities of mineral oil are given orally twice a day and the child is toileted at a regular time each day for 15 minutes in an attempt to establish a normal bowel habit routine. In addition, the child is encouraged to use the commode as often as is necessary at other times of the day. Some physicians have modified this approach to better meet the individual requirements of the child. Review of cases To gain a better understanding of some of the features seen in encopretic cases, we undertook a study of all children who were hospitalized on the Psychiatric Children's Unit at the University of Arkansas Medical Center from 1972 to 1978 with a primary diagnosis of encopresis. During this period, 13 children were admitted for treatment of this disorder, 12 of whom were boys. While encopresis is known to occur more commonly among boys, the male proportion in our review was considerably higher than that reported by Bellman,S who found the male:female ratio to be 3.4: 1. The incidence of encopresis was also higher in our study; of395 children admitted to the Psychiatric Children's Unit, 3.3% were diagnosed as having encopresis. The overall incidence reported in other studies is
1.5%.5 Differences were found among the children in our study in several respects. Six were last-born, while only two were first-born. The onset
of encopresis apparently correlated with the birth of a younger sibling in two of the children. Encopresis followed a painful cystoscopic procedure in one other child, and in another was felt to be associated with a spinal cord injury at the age of 20 months. Five children had never been adequately toilet trained and were considered to be primary soilers. The remaining eight secondary soilers had varied age at onset from 4 to 9 years, with a mean of 6.2 years. The duration of symptoms prior to hospitalization varied from one to four years. Four children had an accompanying nocturnal enuresis; three of these were primary soilers. Moderately severe behavior problems such as aggression, destructiveness, lying, and stealing were evident in six boys, two of whom had also set fires. At least three children displayed significant depression symptomatology, and hyperkinesis was evident in two. Toilet training had been completed before the third year in all children who suffered from secondary encopresis. Family pathology Without exception, the children's families displayed varying degrees of psychopathology. Divorce had broken ten of the 13 families. The other families were intact but living under conditions of severe marital discord; the mothers were the dominant figures in the home and the fathers assumed a more passive role. In two of these families, numerous separations had taken place. Hostility, either overt or covert, was evident in roughly 75% of the mothers. Four mothers showed marked overt hostility and made therapy difficult. Several mothers appeared to be clinically depressed. (continued)
JANUARY 1980· VOL 21 • NO 1
69
Encopresis
Children of divorced families in every instance lived primarily with the mother, and contacts with the natural father were brief, sporadic, or nonexistent. None of the 13 fathers had been involved with the children in significant or meaningful ways. Not unexpectedly, a child's soiling generally worsened with increased turmoil within the home. In most cases, soiling occurred primarily at home in close proximity to the mother. Often, symptoms were exacerbated when a divorced father returned to visit his child in the home. All children in the study had undergone prior treatment for encopresis, either by a family physician or pediatrician or at the local community mental health center. Various treatment methods had been tried without significant therapeutic effects. The parents had utilized a number of punitive as well as nonpunitive approaches to get their child to stop soiling; these were all unsuccessful. All 13 encopretic children had a strong need to deny their symptom. Several seemed unaware that they were soiling their clothing. Some hid their soiled garments in various places during the initial period of hospitalization in order to escape detection. When confronted with this by the nursing staff, they strongly denied any involvement. One child actually complained that while he was asleep his undergarments were stolen by his roommate, who then soiled them and hid them in the closet. Intelligence No child in the study was mentally retarded. Eight had IQ scores that fell within the normal range, whereas five had scores in the superior range. The one child who 70
remained persistently encopretic despite our best therapeutic efforts had a full-scale IQ of 146. Academic performance was commensurate with the child's intellectual capabilities in most cases. Those children who did poorly academically tended to be the more depressed members of the group. Hollingshead's Index of Social Position was used to measure social class status. One child came from a class III home, eight came from class IV homes, and four children from class V homes. Multimodal treatment A multimodal therapeutic approach similar to that described by Halpern 7 was used in the hospital. Behavior modification strategies, using primarily positive reinforcement techniques, were found to be very effective in controlling most children's soiling habits. Weekly group therapy sessions were carried out, in which each child was encouraged to talk about "my problem." Individual therapy using a combined supportive and insight approach proved helpful in most cases. Occupational therapy was found to be a useful adjunct in improving the self-esteem of children with a poor self-image. Finger painting and molding clay, using brown colors, provided a healthy outlet for those children who displayed tendencies toward being "messy." Family therapy and parental counseling were an integral part of treatment, since in the majority of cases soiling was considered symptomatic of a disturbed, dysfunctional family. A strong correlation was found between the continued cessation of a child's encopretic habit and resolution of family conflicts. A modification of Davidson's
method was utilized, primarily in those children whose encopresis was long-standing and in whom toilet training had never been adequately achieved. Following the administration of enemas, these children were initially given appropriate doses of milk of magnesia at bedtime; this laxative was continued throughout their hospitalization. All were required to go to the toilet immediately after breakfast for the purpose of defecating. The requirement of regular toilet attendance proved to be extremely help_ ful in getting the children to establish a normal bowel routine. The following case illustrates Our approach to the treatment of the encopretic child. Case report A 6-year-old boy, the youngest of three children, had been encopretic for two years. After the onset of his encopresis, he had undergone extensive diagnostic studies by a local pediatrician, and no physical basis was found for his problem. The parents had tried both punitive and nonpunitive measures in an attempt to control the soiling, but none had been successful. He was described by his parents as a nervous, fearful child who caused no discipline problem at home or school. Early history was unremarkable. The parents, in their mid305, held managerial positions in separate organizations. Marital discord had increased significantly over the preceding several years. The mother, previously married and divorced, was an aggressive, somewhat hostile individual and the dominant figure in the home. The father was passive by nature, but expressed resentment over the domestic responsibilities thrust upon him by his wife and the role reversal that had taken place in the home. During his free time, he tended to avoid his family. When the child was admitted to the
PSYCHOSOMATICS
Children's Psychiatric Service, he displayed shyness, mild withdrawal behavior, passivity, and difficulty expressing anger. Physical examination and routine laboratory studies were normal. A psychological evaluation revealed a full scale IQ score of 102 on the Wechsler Intelligence Scale for Children. His educational achievement scores were at grade level. No perceptual-motor deficits were evident in an occupational therapy assessment of the child. To promote soil-free periods, behavior modification techniques were utilized. Positive reinforcers consisted of opportunities to participate in those activities that were of value to the child. When soiling occurred, he was required to spend time washing his dirty clothing during his valued activity periods. He soiled two or three times during his first week'in the hospital, but thereafter did not soil again until his first weekend home visit. After his second visit with his parents, his soiling ceased altogether. Other therapeutic modalities included individual psychotherapy, group therapy, occupational therapy, and recreational therapy. During the various therapy sessions, the child was encouraged to express his feelings and become more assertive. In addition, he attended the inpatient school on a daily basis. As time progressed, he began to interact more with his peers. The entire family was seen weekly for family therapy. In these sessions, efforts were directed toward resolving some of the parents' long-standing differences. The mother was encouraged to be less assertive in the home, and the father was directed to spend more time with the child in a meaningful, constructive manner. In time, the mother became less of a dominant force in the family and assumed a different role in the home. During the family therapy sessions, the child and his siblings were encouraged to express their feelings regarding family problems. After six
JANUARY 1980· VOL 21 • NO 1
weeks, the child had reached maximal hospital benefit and was discharged. Subsequent family therapy sessions revealed continued freedom from encopresis as well as improved family functioning.
Treatment results The mean length of hospitalization for the 13 children was 26.7 days, with a range of IS to 52 days. The eight children with secondary encopresis discontinued their soiling during the first week ofhospitalization. The only girl in the study did not soil at any time while in the hospital. In retrospect, hers may not have been a true case of encopresis, as her soiling at home was related to a fearful avoidance of an ou tdoor toilet. Two children stopped soiling by the end of the second week. Once a proper toilet regimen was established, the child with the old spinal cord injury ceased his soiling during the third week of hospitalization. One child continued to soil throughout his hospitalization; however, his frequency of soiling lessened from several times a day to once or twice a week by the time he was discharged from the hospital. The only failure in the group was a child whose mother refused to cooperate with the therapeutic regimen. One child, whose soiling ceased during the first week of hospitalization, subsequently became enuretic. The enuresis was brought under control following institution of imipramine. Also, several children resumed soiling during their first weekend visit home; however, this soiling quickly abated after a return to the hospital setting. Two children who were successfully treated for their encopresis experienced an exacerbation of
their symptoms approximately a year later. In both cases, recurrence was related to severe conflict between the divorced parents fighting to gain custody of the child. The soiling quickly ceased when the children were rehospitalized. Once the children were discharged from the hospital and placed in suitable foster homes, they continued to remain symptom free. Conclusion The encopretic children in this study were primarily boys 'of average to above-average intelligence. All came from disturbed families; divorce had taken place in 10 of the 13 families. In roughly 75% of the cases, the mothers were viewed as being hostile; several were depressed. Separating the encopretic children from their families by placing them in a highly therapeutic hospital setting proved an effective method of treatment. The majority of children overcame their encopretic habit and responded to a multimodal therapeutic approach within the hospital with concurrent family therapy. At the same time, family functioning improved. REFERENCES 1. Kanner L: Child Psychiatry, ed 2. Springfield. III, Charles C Thomas. 1953. 2. Bemporad JR, Pfeifer eM, Gibbs L. et al: Characteristics of encopretic patients and their families. J Am Acad Child Psychiafry 10 272· 292,1971. 3. Hoag JM. Noriss NG, Himeno ET. el al: The encopretic child and his family. J Am Acad Child Psychiatry 10.242·256, 1971. 4. Anthony EJ: An experimental approach to the psychopathology of childhood encopresis. Sr J Meet Psychol30:14f>.175, 1957. 5. Bellman J: Studies in encopresis. Acta Paediatr Scand 170 (suppl):1.151, 1966. 6. Davidson M, Kugler MM, Baver CH: Diagnosis and management In children with severe and protracted constipation and obstipalion. J Pe· diatr 62:261·275, 1963. 7. Halpern WI: The treatment of encopretic chilo dren. JAm Acad Child Psychiatry 16:478·499. 1977.
71