Encopresis (soiling) and Behavior

Encopresis and behavior

By Patience Domowski, LCSW

Encopresis is the term for when a child past toilet training age (around age 4) is still soiling (pooping) in their clothes, and not properly eliminating in the toilet.

This issue occurs often in conjunction with enuresis (night and day wetting their clothes/bed after potty training age), but not always.

Sometimes the soiling is on purpose, but often it is not. Usually children with this problem have constipation issues and cannot feel or control their bowel movements. They often need extra fiber diet, to drink alot of water, and to take laxatives. It can take a while for this problem to clear up. Sometimes this problem occurs from a problem during potty training or just a GI physical issue where their colon gets stretched out and they can’t feel their bowel movements. However, sometimes this is a behavioral issue. In many cases it's a mix of medical and behavioral problem.

When the problem is behavioral, the child may be holding their stool in, or refusing to use the toilet for several reasons. Sometimes the child doesn't plan or mean to do this, it just happens for various reasons. Common reasons include fear of phobia of the toilet/flush (especially public toilets with the auto-flush), past trauma (doesn't have to be related to bathroom issues, but any kind of abuse, especially sexual abuse), child wants to have some control in their life (maybe some external stressors are causing child to feel out of control), they are afraid of the pain of passing hard stool, they don't want to interrupt play time to use the bathroom, they refuse to drink enough water so their stool hardens, diet issues (refuse to eat vegetables, eat only constipating foods like grains and cheese for example) or they are under some sort of stress (such as parents divorce, major move, bullied at school, new sibling, etc). The child may be unaware of why/the reason for this behavior problem. They often are not doing it intentionally.

To address this issue first try to figure out the cause. Rule out medical reasons first.  Is the child diagnosed with constipation or other GI issues, any food sensitivities that cause diarrhea perhaps? Did they have a difficult time being potty trained? Were they taught to ‘hold it’ instead of ‘go’ perhaps at school or daycare? Constipation can be diagnosed via xray by a GI doctor. If this is the problem try laxatives, high fiber diet, drinking alot of water, and anything else the doctor recommends. Using a small stool for the child to prop their feet while using the toilet may help in pushing it out easier.

If the issue is behavioral (or a mix of both) try scheduling mandatory bathroom use. If the child is emptying themselves on a regular schedule it is less likely they will have anything in them to come out at an unplanned time. There are potty watches you can buy or just set a timer and have child use the bathroom every 1-2 hours. Make sure the school is on board. If they are resistant to letting the child use the bathroom that often, have the doctor write a note, or get a 504 plan. Also offering child a reward for using the toilet can be very helpful. They get a small treat (toy, candy, ipad time) for using the toilet at their scheduled time, and maybe additional treat (more of it) if they actually eliminate in the toilet during that attempt. If they go a whole day without accidents maybe they get another reward.

Do not punish for soiling. Often children cannot help it so this will not help. Even if they have some control, if they feel shame about it and have someone upset with them over it they will likely shut down further and it will make the problem worsen. You can, however, give a natural consequence such as they have to help with the clean up after an accident, they have to put their clothes and sheets, etc in the washing machine and help do the laundry. This is not a punishment but it is a consequence. The consequence can help the child think about if it’s easier to eliminate in the potty versus all the work of a clean up from pooping elsewhere. This is often effective if the problem is strictly from the behavioral issue of not wanting to interrupt play or to get up to use bathroom (sometimes called laziness in using the toilet).

Try to have both parents and any other caregivers (grandparents, babysitters, teachers) get on the same page with the toilet scheduling and rewards system. If one main caregiver is handling the problem differently it can impact the effectiveness of the intervention across settings.

If the problems continue, or if the reason is from a past abuse or trauma, it is a good idea to seek out help from a professional child therapist who can help the child work through those issues. Sometimes just having another person talking to the child about the interventions, instead of just the parents, is effective. If the child is experiencing any emotional stress it may be helpful for them to talk to a therapist about the stress and by airing the stress and learning some coping strategies the toileting issues may just go away.

Some additional helpful resources:

https://www.mayoclinic.org/diseases-conditions/encopresis/symptoms-causes/syc-20354494

http://kidshealth.org/en/parents/encopresis.html#

Tips on bedwetting.

Helpful tips for getting a 504 at school.

Where to buy a potty watch.

Book for children explaining this problem: “Bedwetting and Accidents aren’t your fault. Why potty accidents happen and how to make them stop.” by By Dr Steve Hodges “Dr Pooper” and Suzanne Schlosberg (Available on Amazon)

Bedwetting

There are several different reasons children struggle with bedwetting past the age of 4. It’s normal for a child to be unable to hold their bladder all night up to age 4 and sometimes even up to age 7. However after age 7 its considered diagnosable (nocturnal enuresis). If child was nighttime trained and then regressed it could also be a diagnosable problem. See reasons below.

Note: If children are wetting during the daytime past the potty training stage, that is likely a medical problem or trauma related. Seek a doctor’s recommendation.

1)     Medical/Health problem

The child could have a bladder problem, Urinary tract infection (UTI), immature bladder (not ready to be able to hold it all night), some other health issue. It could be genetic too.

Solution: To rule this out see your child’s pediatrician and/or an urologist.

2)     Heavy sleeper

Some kids sleep too heavily at night and are unaware when their bodies need to go. Their body doesn’t automatically wake them up at night to go. 

Solution: Limit fluids a few hours before bedtime, wake them during the night to use the bathroom, try a ‘Bell Pad technique’ device that vibrates or rings when child starts to wet and it wakes them to finish peeing in the bathroom. Try a reward system for a dry bed. If these don’t work there are medications that can help. See urologist for options.

3)     Trauma

If a child has been through a traumatic experience, especially sexual abuse, it can cause bedwetting. The child may be sleeping fitfully, having nightmares, or their body is unconsciously trying to fend off people by wetting self to push people away.

Solution: Seek a child therapist. If you’re not sure if your child has been through a trauma or been abused but you see some signs, have them evaluated by a doctor or therapist.

4)     Behavioral

If the child is refusing to get up during the night or wetting the bed in the morning, it could be because they are lazy and don’t want to get out of bed to use the bathroom. If the other reasons above have been ruled out this might be the problem.

Solution: Provide reward/sticker chart for using bathroom and dry bed. Have child strip sheets off bed and wash them themselves or bring to laundry area for parents. Have child make their own bed with clean sheets (or help make the bed). Have child wash their body themselves in the morning. If problem continues see a therapist.