Nonretentive Encopresis and Toilet Training Refusal

An inappropriate soiling without evidence of fecal constipation and retention is referred to as nonretentive encopresis. Signs and symptoms of nonretentive encopresis include:

*Soiling accompanied by daily bowel movements that are normal in size and consistency

There is rarely an identifiable organic cause for nonretentive encopresis. A medical assessment is usually normal. A full developmental and behavioral assessment is necessary to determine if the child is ready for intervention to correct encopresis. The assessment is also necessary to identify any barriers to success of correcting encopresis, particularly disruptive behavior problems.

Successful therapy depends upon:

*The presence of soft, comfortable bowel movements

*Addressing toilet refusal behavior

Before therapy:

*Daily scheduled positive toilet sits are recommended

*Incentives to reinforce successful defecation during these sits (see our Encopresis Behavior Charts)

*A plan for management of stool withholding agreed on by parents/caretakers and the family physician

Encopresis affects boys more than girls and may go undetected unless health professionals directly inquire about toileting habits.

About 80 to 95 percent of encopresis cases involve fecal constipation and retention. It is estimated that encopresis in which fecal retention is not a primary etiologic component is under-represented in the literature. Most of the time, children with the latter condition have daily, normal size and consistency bowel movements.

An important thing to realize is that you can't really "win" a fight with your child. When an argument escalates, hurtful things are often said, people become reactive, and there is a likelihood of continued miscommunication-and when that happens, nobody wins. When you get into argumentative patterns with your kids, you will simply end up losing ground. Your child will stop listening to your rules, because he'll know that if he argues with you, there's a chance you'll give in. After all, one of the main reasons kids continue to fight with their parents is because they know they might be able to wear us down and get us to change our minds.

Terms used to describe this problem include:

*Functional encopresis

*Primary nonretentive encopresis

*Stool toileting refusal

There are four subgroups these children may be further divided into:

*Those who fail to obtain initial bowel training

*Those who exhibit toilet "phobia"

*Those who use soiling to "manipulate" their environment

*Those who have irritable bowel syndrome

Behavioral characteristics and toileting dynamics of children with nonrententive encopresis are well described; however, few specific treatment guidelines are available for family physicians.

Research of retentive encopresis:

Over the past 20 years the treatment of retentive encopresis has progressed impressively, however, less attention has been paid to the 5 to 20 percent of cases in which constipation is not contributory, or where a child refuses the toilet-training process.

Evaluation for retentive encopresis:

In most cases, the family physician is who first identifies the problem of retentive encopresis and provides an intervention. If the problem is due to the child not being mature enough for toilet training, waiting until the child matures is the sensible answer. Many times, a lack of maturity is not the cause, but it is a child who is behaviorally resistant or parents who need information on effective behavior management or toilet-training techniques.

Evaluation for retentive encopresis:

In most cases, the family physician is who first identifies the problem of retentive encopresis and provides an intervention. If the problem is due to the child not being mature enough for toilet training, waiting until the child matures is the sensible answer. Many times, a lack of maturity is not the cause, but it is a child who is behaviorally resistant or parents who need information on effective behavior management or toilet-training techniques.

Possible causes for retentive encopresis:

The cause for a child's resistance must be identified first. When the cause is determined, specific therapy can be started.

*If the problem is related to a skill deficit such as opening the bathroom door, seating self on toilet or wiping then teaching and reinforcement of those skills the child lacks is preferred to passive waiting.

*If the child is noncompliant with adult instructions, the physician may refer the family to a pediatric psychologist familiar with compliance training techniques.

In either of the two above cases, without active intervention, a strong-willed child may refuse toilet training and create unnecessary stress on the parent-child relationship, which may in turn increase the risk of abuse.

If you have a toddler who exhibits any of the characteristics of retentive encopresis consult with your toddler's pediatrician for an appropriate evaluation and treatment plan.

Disclaimer: *This article is not meant to diagnose, treat or cure any kind of a health problem. These statements have not been evaluated by the Food and Drug Administration. Always consult with your health care provider about any kind of a health problem and especially before beginning any kind of an exercise routine.