The DSM-5 Autism Criteria: A Social rather . . .

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About the authors:

Roy Richard Grinker, PhD received his BA in anthropology from Grinnell College, and his MA and PhD in
anthropology from Harvard University. He has served on the faculties of Harvard University, Carleton College, and
The George Washington University, and was a senior Asian Fellow at the Atlantic Council of the United States in
Washington, DC from 1996-1998.

Managing Encopresis in the Pediatric Setting

By Edward R. Christophersen, PhD, FAAP (Hon) and Matthew Wassom, PhD
Childrens Mercy Hospitals and Clinics, Kansas City, Missouri
Encopresis is defined as a child over the age of 4 repeatedly passing feces into inappropriate places (such as clothing or the floor)
at least once per month over a 3-month period. Encopresis can be primary, in which case the child has never been toilet trained, and
secondary, in which case the child was toilet trained and accident free for a period of at least 6 months. Because constipation
has been implicated in about 90% of cases of encopresis, most of the empirical work has focused on children with a history of
constipation.
Prevalence and Significance of Encopresis
Christophersen and Friman (2010) estimate the prevalence of encopresis to range from approximately 4% of 4-year olds to 1.6%
of 10 year olds, with boys being affected 3 to 6 times more often than girls. Encopresis and constipation have been reported to account
for 3% of pediatric referrals (Loening-Baucke, 1993) and 30% of referrals to pediatric gastroenterologists (Culbert & Banez, 2007).
Har and Croffie (2010) reported that there are no correlations between encopresis and socioeconomic status, the childs position
in the family, parental age, or family size. Population based studies on the prevalence of encopresis in children, beyond American
populations, have been scarce. Van den Berg et al. (2006) reported no evidence that the rate of constipation occurs any less in
non-Western societies.
Encopresis can lead to significant impairment in multiple areas. Parents have rated the childs lack of self-esteem as the most
important consequence of constipation and encopresis while emerging evidence shows that these children may exhibit more
emotional and behavioral difficulties than other children, perhaps as a result of the condition. Despite the commonality of this
condition, encopresis has been referred to as the hidden disease and parents of children with encopresis often think that they are
the only family who has a child with this problem (Christophersen & Friman, 2010). There has been very little discussion about
encopresis in the popular press.
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Etiology of Encopresis
Har & Croffie (2010) stated in their review that 90% of all cases of encopresis are functional in nature, with no obvious medical
cause for the constipation. There may be some predisposing factors present that promote tendency toward constipation such as
genetics towards slow motility, change in diet or poor diet, or dehydration. The most common condition that must be distinguished
from functional constipation in infancy is Hirschsprungs disease.
There is support that stool-withholding behavior is a major cause for the development and persistence of constipation and
encopresis. However, it is felt that stool withholding and anxiety about defecation are preceded by large, hard, and painful difficult
to pass stools (Blum, Taubman, Nemeth, 2004). Because of this relationship between initial difficult stools, withholding behavior,
and then subsequent increased problems with constipation, this condition is often thought of as a self-perpetuating condition.
Long-term fecal retention due to stool withholding eventually may lead to chronic presence of a fecal mass and cause changes in
the functioning of the rectum and lower GI system. Therefore, the maintenance of encopresis can be thought of as both a physical
problem and a learned behavior problem that requires both medical and behavioral intervention.
There has been some limited research on the role that child temperament may play in the further maintenance of stool toileting refusal
and thus encopresis. Taubman (1997) found that there was a trend toward children with stool withholding being rated by their
parents as having a more difficult temperament. Burket and colleagues (2006) showed constipated children aged 2-7 years were
rated by their parents to be more stubborn in general and regarding toileting behaviors.
Evidence Based Assessment
Initial assessment of the child with encopresis should include a thorough medical history and a physical examination by the
physician. It is important to fully evaluate the presence or history of constipation to determine treatment course, as treating encopresis
in children with constipation will differ from treating encopresis when there is no history of constipation. A working group
composed of gastroenterologists and pediatricians published the Rome III criteria for functional constipation which should be used
as a guideline in this evaluation (Rasquin, Di Lorenzo, Forbes, Guiraldes, Hyams, et al., 2006) (See Table 1 for Rome III criteria).
Table 1: Rome III criteria for functional constipation
Must include 2 or more of the following in a child with a developmental age of at least 4 years:
Two or fewer defecations in the toilet per week
At least 1 episode of fecal incontinence per week
History of retentive posturing or excessive volitional stool retention
History of painful or hard bowel movement
Presence of a large fecal mass in the rectum
History of large diameter stools that may obstruct the toilet
*Criteria fulfilled at least once per week for at least 2-months before diagnosis
It is important for the history to include a review of the childs toilet training as well as their response to the training. Examination
of the perineum and perianal area is essential and digital rectal examination, while rarely actually performed in practice, is also recommended. Some physicians also order a kidney, ureter, and bladder (KUB) x-ray to determine the extent of the fecal mass, which
can also sometimes be used to help educate the family. Lastly, physicians should consider a brief screening of other behavioral concerns. A useful behavioral screening measure that can be implemented quickly in the physician office is the Pediatric Symptom
Checklist (PSC) (Jellinek, & Murphy, 1988).
Evidence Based Treatment
The medical-behavioral treatment approach is recommended for children with encopresis associated with functional constipation
(Christophersen & Friman, 2010). This includes 4 major treatment components: 1) education about the condition, 2) disimpaction
of constipation, 3) maintaining regular bowel movements, and 4) behavior strategies to improve toileting habits and behaviors. The
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North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHN) Clinical Practice Guidelines (2006)
also further support this line of treatment approach for management of functional constipation.
Medical-Behavioral Treatment Approach
The education component usually involves making sure that the family understands the role that constipation plays in the etiology
of encopresis including a developmentally appropriate discussion of the anatomy and physiology of the lower GI tract and defecation. It is important to alter negative attributions of the parents about the cause or origin of the soiling accidents. Many parents of
constipated children with encopresis think that the child is soiling on purpose or is being lazy or defiant. Parents should be
educated that the encopresis or loss of feces in the underwear is involuntary and the result of overflow incontinence, deconditioning and altered functioning of the rectum, and learned withholding behavior. In our clinic we use Levines (1982) schematic
representation of the colon of a child with encopresis. The clinician uses the schematic to explain how constipation leads to the
increased diameter of the colon and rectum as well as the decreased sensitivity to pressure in the colon. Parents are coached to
maintain a consistent, positive, and supportive attitude in all aspects of treatment. It is important to include the child in this
education and we often discuss being a team with the child to help this problem go away.
The second treatment component that can be discussed and carried out after providing the education is the treatment of the childs
current constipation and/or impaction. It is important to again provide detailed education about why a clean-out is essential in
the success of treatment and prepare parents for the process. It should be clarified with the child that this means taking medicine
and having a lot of stool out. Disimpaction or clean-out typically involves medication (either oral or rectal - there are no
published studies comparing the 2 routes of administration). The NASPGHN Clinical Practice Guidelines (2006) discuss the
various medications and dosing for relief of constipation, which may involve enemas, suppositories, or oral medication (such as
polyethylene glycol 3350 powder). Absent adequate management and monitoring of the childs constipation, the likelihood of
significant progress is significantly reduced.
The third component is the maintenance of regular and consistent bowel functioning and making sure that the child does not
get constipated again. Christophersen and VanScoyoc (2013) recommend including management of the diet (with increased
consumption of dietary fiber and reduction in the intake of dairy products when indicated, and increased water consumption).
Maintenance may also include the use of stool softeners and laxatives to prevent accumulation of stool and allow the rectum to return
to normal functioning. The 2 most common agents are polyethylene glycol and lactulose, which draw fluid into the large intestine.
Again, NASPGHN Clinical Practice Guidelines (2006) give recommendations for specific medical regimens for maintenance
treatment of constipation.
The fourth component of treatment that occurs concurrently with maintenance medical treatment is behavioral strategies that
promote healthy bowel habits and routines. One helpful approach discussed in the literature and used in our clinic is to work with
parents (and include the older child in the process) to closely monitor bowel output for a period of time to ensure that medication
and diet adjustments can be made when necessary. We routinely ask the parent(s) and child to complete a Bowel Symptom Rating
Sheet (SRS) on a daily basis (See Table 2). This bowel symptom rating sheet helps track bowel movement details such as frequency
of stools in the toilet, soiling accidents, size or volume of stools out, and consistency or appearance of stools out. Often children
who are having slow and insidious onset of constipation can be managed by calculating estimates of weekly stool volumes and
working towards consistency each week. In addition, the SRS can track medication doses given, amount of dietary fiber, amount
of water intake, and other goals which provides the opportunity to quickly and efficiently review not only the patients progress,
but also their level of adherence to the treatment regimen. At the same time, the parent/child completing the SRS is reminded daily
what the components of the treatment regimen are and this can be a motivating intervention.
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Table 2: Bowel Symptom Rating Sheet (SRS)

Behavioral interventions should include scheduled and rewarded toilet sits. Scheduled toilet sits can occur 20-30 minutes after meals
to take advantage of the gastrocolic reflex and because pairing with meals is easier to build into the family routine. Scheduled
toilet sitting improves healthy toilet behavior and responsibility and also helps with reconditioning the rectum by keeping the
rectum empty as much as possible. The time on the toilet should be unrushed and positive and may include special activities that
are only available while on the toilet (special books, toys, or handheld electronics). Toilet sits should generally last 5-10 minutes
but some children need to gradual work their way up to longer sits if there is initial resistance. The key to toilet sits is that the child
has to learn to relax during these sits and hopefully concentrate on the sensations from their lower abdomen.
Positive reinforcement systems should be used for toilet sitting and other successive goals towards appropriate toileting behavior.
Reward systems for toilet sitting compliance can include toilet sit sticker charts, calendars, and also earning tokens/chips/points
that can be used for purchase of incentives or privileges. Typically, we recommend rewarding the patient for cooperation with
the components of the treatment regimen (and not just for proper elimination in the toilet which is rarely achieved early in the
treatment program). Often times there needs to be a progression of successive steps towards toileting that may include focus on
general compliance, completion of the bowel symptom rating sheet with parents, medication adherence, scheduled toilet sit
compliance, changes in diet and water intake, compliance with a clean up routine, bowel movements in the toilet, and periods of
cleanliness or time without soiling.
A specific example of a positive reinforcement system that is relatively easy to implement is reward menus. We ask the parent(s)
to identify 5-6 activities (that dont involve travel or money) that their child enjoys, most of which involve one-on-one
participation with the parent(s). Examples include playing catch, playing on a swing set, going for bicycle rides, favorite board game
or videogame. With younger patients, we will ask the parents to put pictures of the various rewards that they have identified on a
sheet of paper that is posted in the bathroom as a frequent reminder to the patient of the rewards that are available. We generally
recommend to parents that the rewards must be consumed the day they are earned, not saved for the weekend or a better time because
we want immediate reinforcement for a behavior that needs to occur daily.
Other behavioral interventions often need to be implemented in individual patients to address barriers to treatment success. In many
cases, these children would benefit from referral to a behavior specialist. For example, some families need guidance in improving
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the childs general compliance with instructions. This may include providing guidance on positive attending and describing desired
behaviors, consistent limit setting, and using immediate and consistent consequences for noncompliance. Other children may have
significant fears of the toilet or full toilet refusal and need a more gradual approach or systematic desensitization to toilet sitting.
Some children may need more specific behavioral guidance and training for effective defecatory pushing and evacuation of stools.
A particular intervention that was found to be effective, using random controlled assignment to alternative treatments, was enhanced
toilet training, which teaches children appropriate defecation pushing and works on correcting paradoxical contraction and learned
withholding behaviors (Borowitz, Cox, Sutphen, & Kovatchev, 2002).
Adopted from: Christophersen, E.R. & Wassom, M.C. (In Press). Encopresis. In R. Cautin & S. Lilienfeld (Eds.), Encyclopedia
of Clinical Psychology, New York: Wiley-Blackwell.
References
1. Achenbach, T. M. (1991). Manual for the Child Behavior Checklist: 4-18 and 1991 profile. Burlington: University of Vermont, Department
of Psychiatry.
2. Blum, N.J, Taubman, B., Nemeth, N. (2004). During toilet training, constipation occurs before stool toileting refusal. Pediatrics, 113,
e520-522.
3. Borowitz, S.M., Cox, D.J., Sutphen, J.L., Kovatchev, B. (2002). Treatment of childhood encopresis: a randomized trial comparing three
treatment protocols. Journal of Pediatric Gastroenterology and Nutrition, 34, 378-384.
4. Burket, R.C., Cox, D.J., Tam, A.P., Ritterband, L., Borowitz, S., et al. (2006). Does stubbornness have a role in pediatric constipation?
Journal of Developmental and Behavioral Pediatrics, 27, 106-111.
5. Christophersen, E. R., & Friman, P. C. (2010). Elimination Disorders in Children and Adolescents. Cambridge, MA: Hogrefe.
6. Christophersen, E.R. & Wassom, M.C. (In Press). Encopresis. In R. Cautin & S. Lilienfeld (Eds.), Encyclopedia of Clinical Psychology,
New York: Wiley-Blackwell.
7. Christophersen, E.R. & VanScoyoc, S.M. (2013). Treatments that work with children: Empirically supported strategies for managing common childhood problems (Second Edition). Washington, D.C.: American Psychological Association.
8. Clinical Practice Guideline: Evaluation and treatment of constipation in infants and children: Recommendations of the North American Society
for Pediatric Gastroenterology, Hepatology, and Nutrition. (2006). Journal of Pediatric Gastroenterology and Nutrition, 43, e1-e13.
9. Culbert, TP & Banez, GA. (2007). Integrative approaches to childhood constipation and encopresis. Pediatric Clinics of North America,
54, 927-947.
10. Har, A.F. & Croffie, J.M. (2010). Encopresis. Pediatrics in Review, 31, 368-374.
11. Jellinek, M.S. & Murphy, J.M. (1988). Pediatric Symptom Checklist. Boston, MA: Massachusetts General Hospital.
12. Launing-Baucke, V. (1993). Chronic constipation in children. Gastroenterology, 105, 1557-1564.
13. Levine, M.D. (1982). Encopresis: Its potentiation, evaluation, and alleviation. Pediatric Clinics of North America, 29, 315-330.
14. McGrath, ML, Mellon, MW, & Murphy, L. Empirically supported treatments in pediatric psychology: constipation and encopresis. Journal
of Pediatric Psychology, 25, 225-254.
15. Rasquin, A., Di Lorenzo, C., Forbes, D., Guiraldes, E., Hyams, J.S., et al. (2006). Childhood functional gastrointestinal disorders: child/
adolescent. Gastroenterology, 130, 1527-1537.
16. Taubman, B. (1997). Toilet training and toileting refusal for stool only: a prospective study. Pediatrics, 99, 54-58.
17. van den Berg, M.M., Benninga, M.A., Di Lorenzo, C. (2006) Epidemiology of childhood constipation: a systematic review. American Journal
of Gastroenterology, 101, 2401-2409.

About the authors:

Edward R Christophersen, PhD, ABPP is a Professor of Pediatrics at the Childrens Mercy Hospitals
and Clinics, Kansas City, MO. He can be reached at [email protected].
Matthew Wassom, PhD is an Assistant Professor of Pediatrics, at the Childrens Mercy Hospitals and
Clinics, Kansas City, MO.

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