Elimination Disorders: Encopresis

Encopresis occurs when children who are old enough to eliminate waste appropriately repeatedly defecate in inappropriate places such as inside clothing or on the floor. DSM criteria for encopresis state that the behavior must occur once a month for at least 3 months duration before the diagnosis applies. In addition, the child must be at least 4 years old (or developmentally equivalent to a 4 year-old). Generally, encopresis is an involuntary condition.

There are two different varieties of Encopresis: With Constipation and Overflow Incontinence, and Without Constipation and Overflow Incontinence. Children with the Constipation and Overflow Incontinence type produce less than three bowel movements per week. Due to constipation, only part of the total available stool is voided during each of these movements. Portions of the remaining stool then leak out of the bowel, often during the child’s daily activities. When the child’s underlying constipation problem is treated, this form of encopresis generally resolves.

As the name suggests, children experiencing Encopresis without Constipation and Overflow Incontinence show no evidence of constipation. Instead, the child’s feces are usually normal in form, and soiling is intermittent rather than regular. Feces may be emitted in a prominent location (e.g., as an act of defiance) or may be an unintentional consequence of anal self-stimulation (e.g., a variety of masturbation). Encopresis without Constipation and Overflow Incontinence is less common than the first type of Encopresis, and is often associated with Oppositional Defiant Disorder and Conduct Disorder.

Encopresis is much less common than enuresis. According to the DSM, approximately 1% of 5-year old children meet the diagnostic criteria for Encopresis. About 3% of all children treated for a mental disorders meet criteria for the condition. Encopresis is 3 to 6 times more common in males than in females.

Diagnosis of Encopresis

As the majority of encopresis cases involve constipation, it is quite important that symptomatic children receive a thorough medical examination including a rectal examination as part of their diagnostic workup so as to identify any physical or medical conditions that might be causing problems.

Information also needs to be collected concerning the child’s toilet training history and his or her mastery of appropriate toilet skills (e.g., any reversions that may have occurred in the child’s use of these skills, and the circumstances surrounding any reversions. In addition, the child’s dietary and eating habits, and the pattern of soiling incidents (including how frequently soiling occurs, whether soiling is in response to any stresses or issues, and how the child, parents and significant others (family or friends) respond to soiling incidents) must be determined. Knowledge of such information is necessary to demonstrate that diagnostic criteria are met, and may also shed light on environmental and emotional factors related to the disorder.

Treatment of Encopresis

In the case of Encopresis with Constipation and Overflow Incontinence, the primary treatment approach may be medical or physical in nature. Bulk-forming laxatives and/or colonic irrigation may be prescribed, and parents may be urged to add a greater proportion of dietary fiber and water to the child’s dieat. Stool softeners, saline laxatives, or rectally administered glycerin suppositories may also be recommended. Dietary, laxative and physical interventions to discourage constipation may be supplemented with behavioral interventions designed to promote bowel regularity. A sitting schedule may be implemented where the child is asked to sit on the toilet and attempt a bowel movement at regular intervals during the day. Regular eating and sleeping routines are also encouraged to promote bowel regularity.

If constipation does not play an important role in Encopresis, then recommended treatments may be behavioral, and designed to lessen defiant behavior, encourage bowel regularity, or to help children to develop awareness of when they need to use the toilet. Toileting skills may be retaught (or taught for the first time) if appropriate. Biofeedback training, designed to help children strengthen their anal contractor muscles and practice sphincter tightening and relaxing, may also prove helpful. Behavior therapy techniques such as positive reinforcement may be used to reward children’s compliance with appropriate habits, and instances of appropriate defecation.