FAECAL SOILING (ENCOPRESIS)

What is encopresis?
Types of soiling.
Background Information
Effects
Causes

physical causes
psychological determinants
environmental factors

Suggested case study

Soiling occurs because the child has lost the normal anal reflex through excessive constipation and subsequent dilation of the bowel – ‘retention & overflow.’

Primary encopresis – when bowel control has never been established

Secondary encopresis - when bowel control has been established for at least 6 months before the soiling begins

"…any child over the age of four and under the age of 16 who regularly soils his / her underwear and / or bed."

(Herbert,1996)

1. Where there is adequate bowel control, but the child, nevertheless, deposits faeces in inappropriate places
2. Where there is a failure to gain bowel control; the child is unaware that he/ she is soiling, or is aware, but cannot do anything about it
3. When the soiling is due to excessively fluid faeces

BACKGROUND INFORMATION

	Encropresis is not uncommon – 3 in every 100 children entering primary school, aged 5, will still be soiling
	Between the ages of 7 and 8, approximately 2 out of 100 children are soiling
	At 12, approximately 1 in every 100 boys, and some girls are still soiling
	Recorded figures are likely to be underestimated due to the shame and secrecy in families around soiling
	Constipation, or hard bowel movements, cause pain, irritability and a decreased appetite
	Stress / trauma resulting from distressing individual / family / life events affecting the child’s emotional state, can affect the functioning of the bowel (e.g. sexual abuse)
	Due to the secrecy around soiling, parents / carers are more likely to think their child has a unique problem, as most have not heard of another with a soiling problem
	Sometimes associated with behaviour problems (e,g. defiance, non-compliance)
	It is more common in boys than in girls
	Soiling is found in children of all levels of ability and from all walks of life
	Highly significant association between enuresis and encopresis
	Relationship between soiling and low-birth weight

	can lead to fear embarrassment, lowering of self-esteem in a child, which may lead to negative social consequences
	children who soil often try to hide soiled underwear / bedding due to fear of ridicule / punishment
	children are likely to be teased and bullied at school because of the problem
	in some cases children have been suspended, as the staff found it so difficult to manage
	the family can feel bewilderment, frustration, failure, revulsion and anger
	soiling tends to engender negative responses from parents and is one of the most common precipitants of incidents of physical abuse

	majority of soiling cases are due to chronic constipation and withholding stools
	children who have hard movements (pain may also be caused by an anal fissure) may respond by stool withholding (to avoid pain.) The longer the child withhold, the harder and more painful the stool becomes (as the role of the colon and rectum is to absorb water from the stool) Therefore a vicious circle is created of more painful bowel movements, more withholding etc.
	when the bowel is frequently overloaded, the rectal muscles become overactive while the anal muscles relax reflexly in response to the rectal activity. The muscles go on churning to eliminate the blockage, the child has no voluntary control and they soil.

	coercive training / punitive rememdies on behalf of the parents
	role of anxious / overprotective mothers and overly strict fathers (Bellman, 1966)
	tendency of soilers to be nervous (Bellman, 1966)
	tendency of soilers to be food refusers (Bellman, 1966)
	tendency of soilers to suffer from learned helplessness (Sluckin, 1981)

	stressful environments
	poor toilets at home or at school
	separation (and other traumatic) experiences
	dietary factors: eating a diet deficit in fibre and drinking excessive milk can cause constipation in older children.

	The child’s age
	Is it primary or secondary encopresis?
	What toileting skills have they already achieved?
	Does the parent / carer praise progress made / offer the child encouragement?
	When is the child most likely to soil? E.g. time of day / night
	What are the motions like?
	Could there be any physical causes?
	Are there any emotional influences?
	Can you identify any psychological determinants?
	Do any environmental factors come into play?

	Consider A.B.C. model
	Help the parent to think about ways to involve the child
	Help the parents to explore how they can reinforce good behaviour, including encouragement during periods of relapse
	Explore with the parent’s the child’s self-perception and the relationship this has with soiling
	Consider additional techniques (e.g. behaviour programme, cognitive restructuring, helping and encouraging the child to recognise body signals /clean themselves up, modelling, story <Sneaky Poo>)