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. 

Potty Training

Potty Training

If your child is ready for potty training... 
(To be ready the child should be able to notice they are eliminating/voiding, such as going off in the corner to "go", asking for diaper change right away, feeling uncomfortable with a full diaper, showing interest in the bathroom, able to request the bathroom- for verbal children). 
Usually children are around 2-3 years old. (Developmentally delayed children may be around 4-6 yrs old or older.) Occasionally a child is ready around 18 months old. 

-Start putting them in underwear (can put diaper over/under underwear if child makes alot of accidents and its not possible to allow them to wet themselves multiple times per day).
[Note: Some parents let children run naked in the backyard in the summer and when they see them start to go, they rush them to the toilet (like training a puppy). This works for Some kids.]
-Try putting them on the toilet (or baby potty) every 10-30 minutes all day (pick which amount of time works best for you and the child's preschool), routinely (may take days or weeks, especially with kids with special needs it may take months or years).
-Have them sit for about 7-10 minutes at a time on the toilet (use a child's toilet seat on the toilet so the child doesn't fall in!)
-Sing, read a book, watch a movie on a portable DVD player, do puzzles, color a picture, etc. Make it fun! Not a punishment! (If child gets up/won't sit, just hold them on the toilet gently for the count of 10, and let them off of it. Can also try keeping their clothes on at first to get comfortable with it, or try a small baby potty if they are scared of large toilet)
-If they eliminate/void on the toilet, they can immediately get up (don't have to wait the rest of the minutes). Don't forget to wipe! [**Girls should always wipe front to back to prevent infections!!]. Teach child how to wipe themselves. Use wet wipes, then fade out to toilet paper, if you want.
-Give alot of social praise : "Yay! Good job!" high five, hugs, etc "You went on the potty!" and also give a special treat if they "go" that they ONLY get at this time (cupcakes, Popsicle, candy, chocolate, etc).
-Have child flush the toilet, and pull up their underwear (or pull-up)- they may need help, but let them try on their own first, and show them where to put their hands (front and back works better than just the two sides).
- Wash hands!! Even if child didn't void on the toilet, or wipe self they should still learn the importance of washing hands, it gives an extra opportunity to clean hands throughout the day (best way to avoid germs!) plus an opportunity to teach children how to wash hands!

**Note: By about 4 or 5 years old (typical) kids should be able to wipe themselves (may not be super effective if they make a bowel movement, but they should be able to try by themselves first). It may be harder for kids with special needs, if they don't have the right dexterity or can't reach well. Try wet wipes and then move to regular toilet paper.

Additional ideas/information: 
-When beginning to introduce potty training, have child watch you (parents) use the toilet. You could even have child (clothed) sit on your lap when you go to the bathroom, so they see what happens.
-Another idea is to always change child's diaper in the bathroom, when you are starting this process.
-And/or have child sit on toilet or go in bathroom whenever they soil their diaper so they start connecting that when they go in their diaper, it should be in the bathroom.
-Have child flush toilet for parents, or when you put the poo from the diaper in there, for example to help them be more a part of the process and for child to see where poo should go!
- Reading potty training kids books like "Elmo uses the potty" or using potty training dolls can be helpful for some kids. Practicing putting dolly/elmo/bear/etc on the toilet is good idea.
-Potty training sticker charts may work for some kids instead of immediate food/candy rewards.
-Use a step stool/bench under child's feet so they don't dangle if child is scared, and also to push off of to make a bowel movement.
-Have child drink ALOT of water/juice during the day, and on the potty during training.
-Have child change their own clothes or clean up puddles if they have an accident- don't punish them, but stress that pee-pee belongs in the potty.
-If child is dry when its potty time and they had no accidents, praise them, and point out they are dry (specific praise) and emphasize pee goes in the potty.
-Teaching boys to "Aim" .. throw some Cheerios in there and have them try to "sink" the O's! (Don't do this if your child likes to put hands in the potty as he might try to reach in and eat them!)
-Boys need to "point"/Aim DOWN, make sure they hold/push themselves downward (if you know what I mean!) or parents can do it for them until they learn how; otherwise pee will go all over the room, and likely on the parents too! (this always happens at least once when potty training!!) :)
-Teach Boys to SIT first for both pee and poop, then teach them to stand up. (Dad can teach them how to use a urinal). Boys also need to learn how to pee without pulling down their pants all the way in public. This should be taught after they are fully potty trained with the sit-down method for the most part.
-For Girls- always wipe every time- front to back!! To avoid infections and UTIs!
-Boys (especially if uncircumcised) should really wipe even for pee as well to prevent infections too- if a little bit of pee is left on their skin and it gets inside, it can cause some infections/UTIs sometimes.

 Different kids learn different ways so don't be too discouraged if your child needs another method!
Ask your child's preschool teacher, other parents, therapists, and your child's doctor for more ideas or to come up with a unique specific plan for your child if needed! Remember if your child isn't ready, you can take a break and try again later. Also it may take longer than what your friends may tell you and don't feel discouraged- keep trying or try a different method if something doesn't work!

The ideas above come from various experiences and suggestions from teachers, therapists, parents, etc and different experiences I have had working with different professionals and parents with potty training children, especially special needs children.  I hope it helps!

Here's some potty training tips for 3day training- great ideas, though it likely won't work on special needs kids.

 http://yourmodernfamily.com/potty-training-in-three-days-2/