Earlier on in the year, when I wrote about Encopresis (link in the comments (1)), I mentioned that the usual response to my saying the word “Encopresis” is “Enco-what?”. The second most common response (after explaining what encopresis is) is “Oh, so *that’s* what it’s called!”
Encopresis is fairly common, affecting around 4-5% of children aged 5-6, and slowly decreasing with age (2). It is also more common among boys than girls. According to the DSM-5 (the book we psychologists like to quote when wanting to define various issues) encopresis is the repeated passage of feces into inappropriate places, such as on clothing or the floor. It is usually involuntary, though sometimes can be intentional. It can only be diagnosed after the age of 4, and must occur at least once a month for a period of at least three months. It can either be primary (i.e. a child was never fully passing feces on the toilet) or secondary (after a period of training, they resume soiling themselves).
Obviously, this phenomenon is difficult and overwhelming both for parents and the children dealing with it. Part of the difficulty is confusion regarding the *cause* of encopresis, and another aspect is how best to *treat* encopresis.
Over the next few weeks, I hope to discuss these two questions more in depth, using methods learned and practiced at the Encopresis Clinic at Maayanei HaYeshua Medical Center, based on a model written by Professor Esther Cohen (3).
First things first: *why* does encopresis happen? What causes it?
There are a number of different theories, but the fullest explanation involves physical, emotional and behavioral aspects.
Physically: firstly, there are cases of encopresis that are almost completely physically-based (i.e. without an additional behavioral or emotional aspect that *maintains* the encopresis; encopresis will still affect behavior and emotions). These types of cases usually wouldn’t reach us in the clinic, as the first port of call is a family doctor, pediatric gastroenterologist, physical therapist or other professionals. Some examples are Hirschsprung’s disease, spinal issues or more.
But even in the absence of these specific issues, there is a physical element to encopresis.
Very frequently, encopresis develops in the aftermath of constipation. This constipation can come because of physical issues (such as diet), behavioral and emotional ones, or a mix of all three. Once a child is constipated, the stool in their body begins to harden, and a vicious cycle sets off: this causes the colon to enlarge and the muscles to become strained (and weak). Additional fecal matter reaches the colon and can leak out while still liquid (since the system is already overburdened). When the body can no longer retain the stool, it will be expelled (sometimes in great quantity and possibly involuntarily), but some of it will usually remain in the body, causing the cycle to perpetuate itself.
Although constipation is *often* involved in encopresis, it is not *always* so. Additionally, there can be times where from a parent’s point of view, there does not seem to be any issues with constipation at all!
But if encopresis is not *all* physical, what part do behavioral and emotional aspects play? Well, firstly, usually the cycle will be kicked off by an initial occasion in which a child refrained from going when they had to, where they “held it in”. My supervisor would refer to this act as the “original sin” of encopresis, in that (from a physical perspective) it is what causes encopresis to kick off and continue to affect a child and their family.
There is usually some *reason* that a child refrained from going to the bathroom in the first place (assuming that the constipation was not solely a result of diet or other factors), a reason that can sometimes be helpful to know in order to try and stop encopresis from perpetuating.
In the majority of cases, families seeking help mention that there was some issue that made it so their child did not want to go to the bathroom in their daycare setting/school. Often, it’s because of the cleanliness level (perhaps an Encopresis Prevention Unit can tour the country, maintaining high levels of school bathroom cleanliness?), but it can be because of anxiety due to the presence or teasing of other children or just to a lack of time in the school setting (especially if a child is prone to more painful or difficult passing of stool).
As an aside regarding the development of encopresis: if your child is experiencing encopresis it is *not* a sign that they have experienced sexual trauma (as one parent told me a school counselor had informed them). The vast majority of cases develop for the reasons mentioned above.
Okay, back to the topic at hand. Refraining from passing of stool, especially when done repeatedly, sets off the “vicious cycle” mentioned above. At first, it’s possible that a child will still voluntarily go to the bathroom and the system will still work, but as increased strain is put on their body, this becomes more difficult. When at home as well, a child may be distracted by something they are enjoying doing, and (consciously or not) tell their body “Just a few more minutes and I’ll go.” The habit of toilet training, of the child being sensitive to their body’s signals and responding in kind, has been knocked off track.
Parents, when encountering their beloved child who is now often (for reasons not fully understandable) smelly and soiling themselves, will usually be confused, sad for their child, frustrated and more. They will try all sorts of methods to help their child through this issue, sometimes successfully, but sometimes not.
A common by-product of encopresis is tension within the parent-child relationship (and for good reason!). Related to this, discussion of and encouragement of proper bathroom behavior often can become a point of contention between parents and child, paradoxically leading to greater issues with encopresis.
Due to the ever-present signs of encopresis and the emotional aspects that we assign to toilet-training, this means that encopresis can often end up affecting an even larger share of the parent-child relationship. Difficult emotions can be prominently present in the relationship even when both sides want a calm, loving and supportive one. As a result, parents can feel overwhelmed and helpless.
But don’t worry! There is hope! Firstly, a share of cases of encopresis resolve spontaneously, or with minimal parental intervention (4). And for those that do not, there are professionals from whom you can get help. That’s what we’ll speak about in the coming posts!
But one last point before the end: *usually*, a family will first seek guidance from a doctor (before a psychologist) when a child is experiencing constipation and the early stages of encopresis. When the doctor rules out a strictly physical diagnosis (such as some of the issues mentioned above), that may cause parents to feel “There *IS NO* physical issue, it’s *ALL EMOTIONAL*” (as more than one set of parents has told me). Although that formulation is understandable, it usually is not accurate, and more importantly- it’s not very helpful. It ends up putting the blame squarely on the child (or on the parents, if they feel any emotional issue is their “fault”), and can increase parental frustration and anger.
Once again, treatment aspects will come in following posts, but if you have any questions or comments, or would like to reach out to book a session, feel free to post here or message me!
