A Biobehavioral Approach to the Treatment of Functional Encopresis in

Children
Friman, Patrick C., Hofstadter, Kristi ., !ones, Kevin "., The !ournal of Earl# and $ntensive
Behavioral $ntervention
Abstract
Functional encopresis (FE) refers to the repeated passage of feces into inappropriate places at least once per
month for at least 3 months. Treatment of FE targets the processes that cause or exacerbate the condition,
including reduced colonic motility, constipation, and fecal impaction. The cardinal elements of successful
treatment include "demystifying" the elimination process, bowel eacuation, stool softeners, prompts and
reinforcement for proper toileting habits, and dietary modifications. !espite misinformation and
misinterpretations of encopresis, the assessment and treatment of this condition actually represent one of the
more successful achieements of behaior therapy.
"eywords# Encopresis, constipation, fecal incontinence.
$ntroduction
Functional encopresis (FE) is a common, under%treated and often oer%interpreted elimination disorder in
children. &lthough all forms of incontinence re'uire ealuation and treatment, when left untreated FE is more
li(ely than other forms, such as enuresis, to lead to serious and potentially life%threatening medical se'uelae and
impaired social acceptance, relations, and deelopment. The reasons for the medical se'uelae will be
summari)ed briefly below. The primary reason for the social impairment is that soiling eo(es more reulsion
from peers, parents, and careta(ers than other forms of incontinence (and most other behaior problems). &s an
example, seere corporal punishment for fecal accidents was still recommended by professionals in the late
*+th century (,enoch, *--+). Eidence%based practices in the treatment of FE hae eoled substantially since
then, but the approaches by lay persons (and still some professionals) hae not (ept pace. .hildren with FE are
still fre'uently shamed, blamed, and punished for a condition that is most often beyond their control
(.hristophersen / Friman, 01123 Friman, 01133 Friman / 4ones, *++-3 5eine, *+-0).
The definition of FE has remained relatiely consistent across ersions of the !673 the !67%$8 (&merican
9sychiatric &ssociation, *++2) lists four criteria for FE# (*) repeated passage of feces into inappropriate places
whether inoluntary or intentional3 (0) at least one such eent a month for at least 3 months3 (3) chronological
age is at least 2 years (or e'uialent deelopmental leel)3 and, 2) the behaior is not due exclusiely to the
direct physiological effects of a substance or a general medical condition except through a mechanism
inoling constipation. The !67%$8 indicates that approximately *: of fie%year%olds meet the criteria for
encopresis, and males are affected more fre'uently than females.
There are a number of classification schemes for encopresis, but the system most commonly used employs a
retentie ersus nonretentie dichotomy. ;etentie encopresis is defined as fecal soiling with constipation and
oerflow incontinence, whereas nonretentie encopresis occurs without constipation and oerflow incontinence
(&merican 9sychiatric &ssociation, *++2). .hristophersen and 7ortweet (011*) describe constipation as the
passage of large or hard stools, often accompanied by complaints of abdominal pain, infre'uent bowel
moements (fewer than three per wee(), the presence of abdominal masses upon physical examination, and
emotional upset before, during, and after defecation. .onstipation is present in approximately +<: of children
referred for treatment of encopresis, indicating that retentie encopresis is far more common than the
nonretentie classification (5oening%=auc(e, *++>).
9realence
.urrent prealence rates for the occurrence of encopresis are scarce, and many commonly cited figures are
based on studies conducted three or een four decades ago. ;ecent inestigations indicate that the prealence of
encopresis is between *: to 2: of children, depending on the source and age reported. & 6wedish population%
based study found that 1.>: of first grade students and 1.?: of fourth grade students experienced fecal
incontinence (6oderstrom, ,oelc(e, &lenius, 6oderling, / ,@ern, 0112). Encopresis was reported to occur in
2: of - to *0%year%old children in 6outh $ndia (,ac(ett, ,ac(ett, =ha(ta, / Aowers, 011*) and 3: of children
between 3 and *0%years%old in the Bnited 6tates (=loom, 6eeley, ;itchey, / 7cAuire, *++3). 8an der Cal,
=enninga, and ,irasing (011<) indicated that the prealence of encopresis was 2.*: in < to >%year%old children
and *.>: in ** to *0%year%old children in &msterdam. The percentage of affected children in each age group
who had consulted a physician, howeer, was only 3-: and 0?:, respectiely, suggesting that prealence rates
based on physician referrals may be gross underestimates.
Bnderlying 9rocess
6uccessful treatment of FE targets the processes that cause the condition or exacerbate stooling difficulties,
including reduced colonic motility, constipation, and fecal retention, and the arious behaioralDdietary factors
contributing to these conditions, including# (*) insufficient roughage or bul( in the diet3 (0) irregular diet3 (3)
insufficient oral inta(e of fluids3 (2) medications that may hae a side%effect of constipation3 (<) unstructured,
inconsistent, andDor punitie approaches to toilet training3 and (>) toileting aoidance by the child. &ny of these
factors, singly or in combination, places the child at ris( for reduced colonic motility, actual constipation, and
corresponding uncomfortable or painful bowel moements. Bncomfortable or painful bowel moements, in
turn, negatiely reinforce fecal retention, and retention leads to a regressie reciprocal cycle often resulting in
regular fecal accidents. Chen the constipation is seere or the cycle is chronic, fecal impaction may result from
the collection of hard dry stool on the colon rectum. Eot infre'uently, li'uid fecal matter will seep around the
fecal mass, producing "paradoxical diarrhea." &lthough the child is actually constipated, the watery, foul%
smelling lea(age produced can be misdiagnosed as diarrhea. $n such cases, parents may inadertently worsen
the problem by administering oer%the%counter antidiarrheal agents (.hristophersen / 7ortweet, 011*3 5eine,
*+-0).
$n a minority of cases, fecal incontinence does not inole problems with colonic motility or constipation. For
these children, fecal incontinence is characteri)ed by regular, well%formed, soft bowel moements that occur
somewhere other than the toilet. The process underlying these cases is not well understood except that they tend
to be treatment resistant (.hristophersen / Friman, 01123 Friman, 01133 Friman / 4ones, *++-3 5andman /
;appaport, *+-<).
&ssessment
The therapist faced with an encopretic child should essentially go no further with treatment until the child has
receied a medical ealuation. Table * displays a series of steps, beginning with assessment, which outline a
comprehensie biobehaioral treatment. The medical ealuation will typically inole a thorough medical,
dietary, and bowel history. $n addition, abdominal palpitation and rectal examination are used to chec( for large
amounts of fecal matter, ery dry fecal matter in the rectal ault, and poor sphincter tone. &pproximately ?1:
of constipation can be determined on physical exam and detection can be increased to aboe +1: with a "B=
(x%ray of (idneys, urethra, and bladder) (=arr, 5eine, / Cat(ins, *+?+). The medical ris( posed by fecal
matter accumulating in an organ with a limited amount of space is serious, and childrenFs colonic systems can
become painfully and dangerously distended, sometimes to the point of being life threatening (7cAuire,
;othenberg, / Tyler, *+-3).
.ertain medical conditions can also be identified during a thorough examination. The most common organic
cause of bowel dysfunction is ,irschsprungFs disease, a condition inoling segments of non%enerated tissue in
the colon. 7any symptoms of ,irschsprungFs disease are rarely seen in children with encopresis. For example,
fecal incontinence is rare in children with ,irschsprungFs disease, whereas soiling is the primary symptom
associated with encopresis. Therapists are encouraged to consult publications that further compare and contrast
the two disorders (.hristophersen / 7ortweet, 011*3 5eine, *+-*). $n addition, slow or absent weight gain in
children who are below age expected weight leels may indicate a malabsorption syndrome and thus re'uire
speciali)ed medical treatment (=arr et al., *+?+).
$nitial ealuation should also include a thorough psychological history. $n a small percentage of cases FE is
secondary to extraordinary emotional disturbance and thus resistant to behaioralDmedical treatment focused
primarily on FE (5andman / ;appaport, *+-<). $n such cases, the emotional condition may be a treatment
priority especially when there is no eidence of constipation or fecal retention. $t should be noted, howeer, that
although some children with FE also hae psychological problems, the incidence of clinically significant leels
of behaior problems in encopretic samples is simply too low to suggest a causal relationship between the two
conditions (Friman, 7athews, Finney, / .hristopherson, *+--3 Aabel, ,egedus, Cald, .handra, / .hiponis,
*+->3 5oening%=auc(e, .rui(shan(, / 6aage, *+-?). Thus, targeting psychological problems in order to
obtain fecal continence would seem imprudent from the perspectie of the scientific literature. ;ather, when FE
and behaioralDpsychological problems co%occur, they often hae to be treated separately. For example, children
who hae poorly deeloped instructional control s(ills are at ris( for being noncompliant with treatment and
thus instructional control training may need to precede or accompany treatment for FE.
&ssessment toward the management of encopresis should include a reiew of the childFs medical history,
toileting habits, and bowel moements, with particular attention to symptoms of constipation. &ny prior
interentions attempted by primary care physicians, other professionals, and the childFs parents should be
discussed, including an assessment of punishment history (e.g., !oes the child hide soiled clothesG), parent
motiation, and child motiation. 5ast, the interiew should include 'uestions about the childFs diet and timing
of meals, as a low%fiber diet and irregular eating schedule may contribute to encopresis (.hristophersen /
7ortweet, 011*3 .hristophersen / Friman, 01123 Friman, 01133 Friman / 4ones, *++-).
Treatment of ;etentie FE
!emystification. &lthough the child is the target of treatment, the parent or guardian is the deliery agent and
thus the primary recipient of the information about treatment. Cith the child present, the therapist should
discuss treatment in general terms, express optimism about potential outcomes, and "demystify" the elimination
process (5eine, *+-0). $n most cases, the parents (and child) will benefit from iewing a diagram of abnormal
bowel functioning that (a) describes how each element of treatment wor(s and (b) communicates clearly that
the childFs bowel problems are not intentional or the result of stubbornness, immaturity, or la)iness. $t is
essential that parents understand that FE should no more be a target for censure and blame than should a
disordered process of respiration, digestion, or motor moement. &s indicated aboe, the literature does not
reflect a significant association between psychological profiles and child bowel problems. Thus, any punitie
parental responses towards fecal accidents, whether perceied as intentional or unintentional, should be
terminated. ;e'uesting a erbal commitment to this effect from the parent, in the presence of the child, may
substantially increase child motiation to participate.
=owel eacuation. & critical step in the inauguration and continuation of effectie treatment is complete bowel
eacuation. The ultimate goal for treatment is for this step to be completed regularly by the child. &t the
beginning of treatment, howeer, they are usually unable and thuse the process must initiated by caregiers.
Eeeded is a full cleansing of the bowel of resident fecal matter and this is accomplished using a combination of
enemas, suppositories, or laxaties. &lthough the therapist can assist with the prescription of these (e.g., with
suggestions about timing, interactional style, behaioral management, etc.) the eacuation procedure must be
prescribed and oerseen by the childFs physician. Typically, eacuation procedures are conducted in the childFs
home, but hospitali)ation may be necessary if constipation is extremely seere or home compliance is li(ely to
be poor. The ultimate goal, howeer, should be complete parent management of eacuation procedures, because
these techni'ues are to be used wheneer the childFs eliminational pattern suggests excessie fecal retention
(.hristophersen / 7ortweet, 011*3 5eine, *+-0).
Toileting schedule. Hnce fecal matter has been successfully eacuated, the parent and therapist should choose
one or two regular times per day (<%*1 minutes) for the child to attempt bowel moements, regardless of the
childFs perceied "urge" to defecate. The time should not be during school hours, because unpleasant social
responses to bowel moements in the school setting may negatiely reinforce retention. .hoices among the
times that remain (morning, afternoon, or eening) should be guided by the childFs typical habits and child%
parent time constraints. Establishing a time shortly after food inta(e may increase chances of success through
the influence of the gastro colonic reflex. The time the child is re'uired to sit on the toilet should be limited to
*1 or fewer minutes in order to aoid unnecessarily increasing the aersie properties of the toileting
experience. The childFs feet should be supported by a flat surface (e.g., floor or a small stool) to increase
comfort, maintain circulation in the extremities, and facilitate the abdominal push necessary to expel fecal
matter from the body. !uring the initial wee(, parent modeling of the "8alsala maneuer" (grunting push
necessary to produce a bowel moement) may be used to facilitate s(ills and aoid the perception of
punishment (.ox, 6utphen, 5ing, Iuillian, / =orowit), *++>). &llowing children to listen to music, read, or
tal( with the parent can improe child attitude toward toileting re'uirements. Aenerally, toileting should be a
relaxed, pleasant, and ultimately priate affair.
7onitoring. Fre'uent monitoring will allow for early detection of accidents, assessment of progress, and
multiple opportunities for praise. Two leels of monitoring are usually employed. First, a regular "pants chec("
should be conducted by parents that results in praise when pants are accident free and a cleaning routine when
they are not. 6econd, a daily record of toileting successes and accidents, along with the si)e and consistency of
both should be documented. ;ecording is made easier by proiding the parent with a user%friendly data sheet
(Friman / 4ones, *++-).
Feedbac(. $f the child has a bowel moement in the toilet, he or she should be praised and, in the early stages of
treatment, proided with a salient reward (e.g., stic(ers, grab bag). 9erformance feedbac( in the form of a dot%
to%dot chart, with a pri)e awarded when all dots are connected, may also be employed (.hristophersen /
Friman, 01123 Friman, 01133 Friman / 4ones, *++-). .hildren should earn praise and rewards for any bowel
moements in the toilet, een if they had a prior accident. $f the child does not hae a bowel moement, their
effort should be praised and another session should be scheduled for later in the day. &ccidents, on the other
hand, should not be the ob@ect of punishment or criticism. ;ather, the child should participate in cleaning up the
mess that has been made. Cith younger children, a one%step procedure that inoles merely bringing soiled
clothing to the laundry area may be sufficient. Cith older children, the cleaning routine may include complete
management, including loading the laundry, cleaning their person, and redressing (;eimers, *++>). ;egardless,
parents should use a neutral and matter%of%fact tone and refrain from erbal reprimands when directing these
conse'uences.
$n treatment resistant cases, howeer, mild aersie conse'uences are sometimes used. &lthough there is little
documentation of their effects, there is ample eidence of their use. & procedure called positie practice
inoles intensie practice of appropriate toileting behaiors following detection of an accident. Hne example
of this type of oercorrection procedure includes a series of Fdry runF trips to the bathroom from locations near
detection of the accident (.hristophersen / 7ortweet, 011*).
.leanliness training. 6uccessful toileting is a complex arrangement of small tas(s and two that are critical to
oerall success but often oerloo(ed in fecal incontinence programs are wiping and flushing. The therapist
should proide the parents instructions on how to motiate and teach children to complete these tas(s.
!ietary changes. !iet often plays a causal role in FE and dietary changes are almost always part of treatment
(6tar(, Hwens%6teely, 6pirito, 5ewis, / Aoernment, *++13 Cilliams, =ollela, / Cynder, *++<). Fiber
increases colonic motility and the moisture in colonic contents and thus facilitates easier and more regular
bowel moements. Fruits, egetables, bran%based cereals, peanut butter, and unbuttered popcorn will appeal to
een the most finic(y eaters. To aid the parents, therapists should proide an educational handout outlining the
actual grams of dietary fiber per (.hristophersen / 7ortweet, 011*), as well as a guide for oer%the%counter
preparations with dense fiber content (e.g., 7etamucil, 9erdiem).
Facilitating medication. 6uccessful treatment of FE will almost always re'uire inclusion of medications that
soften fecal matter, ease its migration through the colon, andDor aid its expulsion from the rectum. The most
fre'uently used substance is mineral oil, either alone or in combination with other ingredients, such as mil( of
magnesia. &lthough there has been some concern regarding the possible deleterious effects of such lubricants
on child nutritional status, recent research has not detected any negatie effects (.hristopherson / 7ortweet,
011*). 9rescription of the substance (and the type) is the physicianFs prerogatie, but therapists can monitor and
ensure compliance. .hildren will often resist the odd taste and texture of these substances, and it may be
necessary to mix the laxaties with a preferred @uice.
$n rare cases, a more inasie substance such as glycerin suppositories are prescribed by physicians, because
their use increases the predictability of bowel moements and reduces the li(elihood of an out%of%home
accident. $t is recommended that suppositories be used in the following se'uence. 9rior to the meal closest in
time to the regularly scheduled toileting, the child should attempt a bowel moement and, if successful, no
suppository is gien. $f unsuccessful, the suppository should be inserted by the parent, and another attempt
made after the meal. 6uppositories will often lead to child resistance, but therapist can assist the process by
teaching the child relaxation s(ills and proiding parents with instructional and motiational procedures to
enhance compliance.
Fading facilitatie medication. &fter the child is routinely accident free and achieing successful bowel
moements in the toilet, a withdrawal of facilitatie medication may begin. & fre'uently used withdrawal
method is to eliminate the medication one day a wee(, contingent upon a series of *2 consecutie accident free,
successful toileting days. The child may be allowed to choose the day. This system should continue, as the child
and parent negotiate a gradual decrease in the criterion number of successful days, until the medication is
completed faded out.
Eidence of Effectieness
The genesis of combined medicalDbehaioral approaches to managing encopresis was 7urray !aidsonFs three%
phase treatment protocol (!aidson, *+<-). The regimen inoled cleaning out the colon with enemas and
putting the child on a daily dose of mineral oil. Eext, diet management included a decrease in dairy products
and increases in fruits and egetables, while eliminating enemas and establishing successful bowel habits. The
final phase inoled the gradual fading of mineral oils. $nitial ealuation reealed a +1: success rate
(!aidson, "ugler, / =auer, *+>3).
!uring the past 01 years, seeral descriptie and controlled experimental studies hae established the efficacy
of multi%component biobehaioral approach, based largely on !aidsonFs pediatric regimen, which is now listed
among empirically supported treatments by the 4ournal of 9ediatric 9sychology (7cArath, 7ellon, / 7urphy,
0111). This literature indicates that a relatiely simple treatment consisting of bowel eacuation, stool softeners,
and positie reinforcement of toileting routines is an appropriate first%step approach (Cright, *+?<3 HF=rien,
;oss, / .hristopherson, *+->). & group format for deliering parent education components has also been
highly successful (6tar( et al., *++1) as has an interactie internet based program (;itterbrand et al., 0113).
;elatiely few studies hae compared the isolated or additie effects of medical or behaioral treatment
components. Two studies by .ox and colleagues (.ox et al., *++>3 .ox, 6utphen, =orowit), "oatche, /
5ing, *++-) compared the additie effects of laxatie therapy, enhanced toilet training, and biofeedbac(.
Enhanced toilet training included the gradual reduction of laxaties, parent education, incenties for proper
toileting routines, as well as modeling and instructions on defecation straining (e.g., constriction of the external
anal sphincter). ;esults of both studies supported a combination of intensie laxatie therapy and enhanced
toilet training. $mportantly, reductions in encopresis were also associated with increases in the fre'uency of
bowel moements, which is consistent with the assumption that encopresis is a function of constipation and
oerflow incontinence.
&t least two studies hae undermined the concern that direct treatment approaches target only the symptoms of
FE, and thus may produce behaioral or psychological side effects (e.g., symptom substitution). The first study
used a behaioral inentory conducted before treatment, post%treatment, and at 3%year follow%up to compare a
group of treatment responders and non%responders to determine whether any significant symptom substitution
occurred in children cured of FE (5eine, 7a)onson, / =a(ow, *+-13 Joung, =rennen, =a(er, / =a(er, *++<).
=oth studies concluded that successful treatment was not accompanied by any problematic behaioral side
effects.
Eonretentie Encopresis
Treatment of nonretentie FE (without constipation) is not well established, thus recommending an optimal
course of treatment is premature. The nonretentie encopretic child has only one or two accidents a day, with
normal stool si)e and consistency. 8irtually all inestigators who hae described this subsample of children
report emotional and behaioral problems and treatment resistance (5andman / ;appaport, *+-<), thus the best
approach would begin with a comprehensie psychological ealuation that includes behaioral assessment
techni'ues. Treatment for this subgroup has employed combinations of medical and behaioral strategies, with
a particular emphasis on supportie erbal therapy (5andman / ;appaport, *+-<) and parent management of
childrenFs misbehaior (6tar( et al., *++1). .learly, the arious behaioral challenges warrant some form of
treatment, but the soiling itself needs direct treatment as well.
.onclusion
FE is a commonly obsered condition that has been misunderstood, misinterpreted, and mistreated for
centuries. ;ecent studies, howeer, hae led to a biobehaioral understanding of FEFs causal conditions and an
empirically supported approach to its treatment. The biobehaioral approach addresses the physiology of
defecation primarily and addresses the psychology of the child as a set of ariables that are not causal but can
be critical to actie participation in treatment. &lthough ealuation and treatment of FE absolutely re'uire the
direct inolement of a physician, ideal management inoles a partnership between the physician, therapist,
and family. $n simple terms, the physician prescribes the treatment for FE, especially the parts pertaining to
defecation dynamics and eacuation of the colon, changing the texture of fecal matter, and increasing colonic
motility in particular. $n an alliance with the physician (and family), the therapist addresses the educational,
behaioral, and motiational ariables that are critical to the implementation of treatment and successful
outcome.
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6tar(, Hwens%6tiely, 6pirito, 5ewis, / Aueremont. (*++1). Aroup behaioral treatment of retentie FE.
4ournal of 9ediatric 9sychology, *<, ><+%>?*.
6oderstrom, B., ,oelc(e, 7., &lenius, 5., 6oderling, &. .., / ,@ern, &. (0112). Brinary and faecal
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an der Cal, 7. F., =enninga, 7. &., / ,irasing, ;. &. (011<). The prealence of encopresis in a multicultural
population. 4ournal of 9ediatric Aastroenterology and Eutrition, 21, 32<%32-.
Cilliams, .. 5., =ollela, 7., / Cynder, E. 5. (*++<). & new recommendation for dietary fiber in childhood.
9ediatrics, +>, +-<%+--.
Cright, 5. (*+?<). Hutcome of a standardi)ed program for treating psychogenic encopresis. 9rofessional
9sychology, >, 2<3%2<>.
Joung, 7.,., =rennen, 5..., =a(er, ;.!., / =a(er, 6.6. (*++<). Functional FE# 6ymptom reduction and
behaioral improement. !eelopmental and =ehaioral 9ediatrics, *>, 00>%030.
&uthor .ontact $nformation#
9atric( .. Friman, 9h.!., &=99
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Table *
6ample =iobehaioral Treatment 9lan
*. ;efer to appropriately trained physician for ealuation.
0. !emystify bowel moements and problems and eliminate all punishment.
3. .ompletely eacuate bowel. 9rocedures are prescribed and oerseen
by physician.
2. Establish regular toileting schedule. Ensure that childFs feet are
on a flat surface during toileting.
<. Establish monitoring and motiational system.
>. 9roide feedbac(. 9raise attempts and successes, and re'uire
child participation in clean up for accidents.
?. Teach appropriate wiping and flushing.
-. $mplement dietary changes that include regularity of meals and
increases in fluid and fiber inta(e.
+. Btili)e facilitatie medication. Chat, when, and how much to be
established by physician.
*1. Establish method for fading facilitatie medication.