My son is eight years old. He has messes in his pants almost every day. We have tried everything to get him to notice that he needs to go to the bathroom. But he just doesn’t seem to notice that he has to go to the bathroom. A few times recently, he has messed in his pants at school. His teacher is very concerned that she may be pressuring him too much in class. His father and I were divorced three years ago, about the time when we think this problem started. We were kind of hoping that our son would just grow out of it.
“Messing” in one’s clothing is often called soiling. The clinical term is encopresis. The elimination disorder, encopresis is the repeated passage of fecal matter, by children older than four, in inappropriate places. Usually this “accident” is involuntary, but sometimes it is purposeful. Soiling is not as prevalent a problem as enuresis. Studies show that about two percent of eight year old boys and one percent of eight year old girls have regular problems with soiling. Soiling is very rare by adulthood.
Soiling is usually misunderstood by parents and school personnel. Many adults see soiling as anger related and controlling. Most families are embarrassed by the problem and thus reluctant to seek help. Many families become punitive with the soiling child; this tends to worsen the problem.
It is rare that “poor” toilet training is the cause of soiling. It is very rare that children spitefully soil. ( Although I have worked with children in in-patient facilities who did learn to control their parents by soiling into their own hand and throwing the fecal matter at them.) I stress that this is rare, and it has been my experience that parents readily ask for professional help in this type of situation.
In the vast majority of soiling situations the problem is the side effect of severe constipation due to feces retention. Ally, a little girl of seven, was very upset about a new baby entering the home. She refused to use the bathroom even though she had been toilet trained for over three years. She begged and pleaded with her parents to let her use a diaper. At first no one noticed that she was not toileting herself. About two weeks after her little brother came home from the hospital Ally had an accident when she was walking home from school. Over the next few months she soiled almost every afternoon. Ally’s mother talked with the family doctor who assured her that Ally “...was just adjusting to the new baby in the house.” When I met Ally she was the center of the family. Everyone was worried about her. Even Ally. She thought that she was sick and her “guts were going to fall out.”
The above situation is typical of how soiling can become a major problem. Research has shown us that most encopritic children have no medical condition that is causing the problem. But, interestingly enough, one of their parents were prone to constipation when they were a child. The cycle begins this way. For whatever reason a child begins to resist defecating. It may be because they are upset about the attention a new baby is getting or they just feel out of control in some part of their life. The child feels control within themselves by not going to the toilet. This retention leads to constipation. Constipation leads to discomfort when defecating. This leads to further retention. In a matter of a few days to a week the child is impacted. She loses the urge to defecate. The child keeps eating, but no waste gets out. As the retention continues, the bowel stretches. As the lower bowel becomes more and more distended (swollen from internal pressure) the child’s anus remains partially open. A little seepage occurs even though a true bowel movement is restricted by the retained blockage.
It is common for the psychological factors that attributed to the initial retention to be solved and the soiling to continue. Ally, had been soiling for over three months, long after she got used to the new baby.
Parents have had great success in stopping soiling by using behavioral interventions. There are three parts to this process. Your child may need all three or just one or two.
1. Your child needs to feel safe within the family.
2. We need to regulate food intake.
3. We need to get your child toileting on a routine.
I cannot over emphasize the fact that your child needs to share his problems with others within the family. I advocate that your child hear that “we” have a soiling problem. Parents need to advocate for their child. I am sure he feels deep shame due to the soiling. This shame tends to be exhibited as an “I don’t care attitude” for older children and adolescents.
I advocate that parents focus on how their child is dealing with the problem, versus the problem itself. Depending on the emotional maturity of the child he should be dealing with the soiled clothing and take responsibility for keeping clean. The goal is for this to become a Minor Rule in the future. At this point the process of taking care of himself should be a Must Rule. One family found the following Must Rule very helpful (This child tended to soil between 4-6 PM):
Must Rule: If you soil yourself, you will take responsibility to clean yourself, rinse out your soiled clothing and place them by the washing machine.
Consequence: If you are soiled for more than three minutes, for every minute it takes you to get into the shower you choose to lose ten minutes of TV.
Please note that the consequence was not directed at the soiling. It was directed at the child taking care of himself appropriately.
The human body has a tube (the digestive system) running through it. This tube starts at the mouth and ends at the anus. We need to deal with the impacted colon so that your child can digest and evacuate waste properly.
Once the colon is distended (swollen by internal pressure) your child will not notice the natural alarm that indicates the need to defecate. As long as the child is impacted this alarm will not trigger correctly.
So, first things first. Your child needs to pass the impacted waste. Obtain from you local drugstore two Fleet enemas. Follow the directions on the packaging carefully. Most children are able to pass the retained blockage with one enema. Sometimes two enemas are needed. This is not a punishing situation. Explain to your child about the process described above and how important it is that his bowel function correctly. Most children are looking forward to solving the problem, so they are cooperative. Sometimes parents need to elicit the help of the child’s medical doctor to administer the enema. (Most doctors turn this medical procedure over to their nursing staff.)
Once the blockage has been passed it will take a few weeks for the colon to reestablish normal muscle tension. During this time, and into the future, what goes into the mouth is most important. Simply put, your child should eat a well balanced diet of food that does not get soft in water. The intestines need roughage (fiber) to squeeze against as it forces food from the stomach to the anus. This process is called peristalsis, a wave like muscular contraction that moves digesting matter through the digestive system. Aim for fresh and cooked vegetables, fresh and dried fruits, and pastas. Avoid sweets, pastries, and low fiber “fluffo” breads.
In the beginning most parents find that a few prunes a day really helps their child keep the digestive tract running smoothly. (If things are running too smoothly, cut back on the fruit.)
This tends to solve about half of the problem. The problem of your child being constipated. We also have to reteach your child to recognize the “call to” defecate.
This is often harder than it sounds. We need to reteach toilet training. Not the whole process, just the, “Oh yeah, I need to poop” knowledge. This is done by setting a routine. Simply put, your child needs to perch his derriere on a toilet three times a day until he is noticing his need to use the toilet. This works best by having your child sit on the toilet for ten minutes after every meal. And, please note, the meals need to be at regular times. Say breakfast at 8 AM, lunch at noon, and dinner at 6 PM This routine is very important in changing the cycle of soiling. In a week or two it will become apparent that at a certain time (sometimes twice) your child needs to defecate. At that point, the potty perching schedule can change to reflect your child’s new self control. Most families find it helpful to keep a chart.
If there is an incident of soiling, then the schedule is reevaluated. One family I worked with found that 8, noon and 6 didn’t work. For their child wake-up and just before bed worked perfectly.
If your child is in discomfort it may be best to consult with your family doctor. Your doctor can evaluate if a stool softener medication would be in order. A registered dietician can be very helpful in developing a healthy diet for your child as well as your whole family. Soiling is a treatable problem. Please reach out to local professional resources. With the correct diet, routine toileting, and a supportive environment, most children tend to retrain their lower bowel in a few months.