Many children, and even some adults, have ever suffered from some form of incontinence, be it urinary or fecal. With regard to faecal incontinence , in a large number of cases we can find that this loss of control may be due to a disease such as gastroenteritis or epilepsy, the loss of muscle tone in the sphincters due to age, the presence of alterations such as those caused by surgery or the consumption of some substances.
But the cause is not always organic: sometimes sensations and emotions such as fear or anxiety, or even laughter, can culminate in at least some of our organic waste not being able to be retained (there are even popular expressions about this). When this occurs in the absence of pathology and in a frequent way we are talking about a problem or disorder called encopresis, and if it occurs in children it is called infantile encopresis .
An excretion disorder
Encopresis is a disorder characterized by repeated and frequent stool deposition over a minimum of three months in inappropriate places such as clothing or soil, and may be involuntary or voluntary.
For the diagnosis of this disorder, classified as excretory disorder together with enuresis or urinary incontinence, it is necessary that the subject is at least four years old (at which time a large part of children already have control of their sphincters) and the incontinence is not due to the presence of a disease or physiological alteration beyond possible constipation, nor to the consumption of substances such as laxatives or food in poor condition.
This disorder may cause the presence of deep feelings of shame or guilt in the child , which sometimes ends up leading to problems in bonding with others, as well as the concealment of bowel movements when they occur involuntarily.
Types of encopresis according to sphincter control
Infant encopresis can be classified into primary and secondary depending on whether the problem is that the minor has not controlled the excretion process at any time or is due to a lack of control produced by some specific element.
Primary or continuous encopresis is that in which the child has not shown at any time that he or she is capable of controlling the emission of faeces, despite already having a sufficiently advanced level of development to be able to do so.
Also called discontinuous encopresis, in it the subject in has previously acquired good control of his sphincters and stool output, but for some reason at present has stopped doing so. In other words, in secondary encopresis incontinence is not due to the child not having been able to control defecation previously.
Types of encopresis according to the level of stool retention
Infant encopresis can be divided in two depending on whether excretion occurs in the face of excessive retention of stool by the child or in the absence of any type of constipation .
Retentive encopresis or with constipation and overflow incontinence occurs when the child retains the release of stool for a long time, and can go up to two weeks without defecating. The child ends up having an overflowing stool, first expelling flimsy stools and then hard, highly consistent stools which involves a certain level of pain to expel .
Encopresis not retentive
In this type of encopresis without constipation or overflow incontinence there is no excessively prolonged retention , and no serious constipation. The child’s stools are normal.
Possible causes (etiology)
Over time, the possible causes of this disorder have been explored, and it has been found that the main causes of childhood encopresis are psychological. However, there are organic factors that can influence its presence such as the tendency to constipation.
When encopresis is primary, it is considered that it may be due to the child’s failure to achieve incorrect learning of sphincter control, with the child not being able to recognize the signals that warn of the need to defecate.
In the case of secondary encopresis, the main aetiology is the existence of some kind of sensation that causes the child to retain the stool or lose control over it. Fear and anxiety are some of the emotions that can elicit such loss of control.Living in conflictive situations, with domestic violence or in precarious conditions may cause some children to react by suffering from this disorder.
Another aspect that is very much linked to is the type of education given to the child : over-demanding by parents who provide too rigid an education can generate fear of failure and punishment that can result in a loss of control, or in the case of an excessively permissive or ambivalent education that causes them insecurity or fear of facing the outside world. In cases where defecation in inappropriate places is voluntary, this may be a sign of rebellion on the part of the child.
The treatment of encopresis usually incorporates a multidisciplinary methodology, incorporating psychological, medical and nutritional aspects .
As far as psychological treatment is concerned, it will focus on the performance of a training in defecation habits which will be enhanced by the use of positive reinforcement. Firstly, it should be evaluated whether there is an emotional reason behind the defecation and/or stool retention, and if so, it should be treated by appropriate means. For example, systematic desensitization or relaxation in cases of anxiety.
As for the defecation process itself, the child will be taught first to identify the signs that warn of the need to evacuate, and then to shape and model the practice of appropriate habits so that the child becomes increasingly autonomous.
At all times, the acquisition of behaviour will be reinforced, and techniques such as token economy can be used for this purpose, both before, during and after defecation (when the child goes to the toilet, he or she evacuates in the toilet and remains clean). Occasionally, punishment has also been used as part of the process, such as making the child clean his dirty clothes, but it is essential not to cause guilt or decrease the child’s self-esteem.
Medical and nutritional intervention
With regard to nutrition and medical aspects, apart from assessing whether the incontinence is not due to organic causes , drugs can be prescribed to help with evacuation in specific situations or enemas to soften the stool in the event of constipation. In fact, the doctor and psychologist should guide the use of laxatives while training in defecation habits.
It is also advisable to provide the infant with a balanced diet rich in fibre that helps the child to carry out his bowel movements in a normative way, together with abundant hydration.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Fifth edition. DSM-V. Masson, Barcelona.
- Thief, A. (2012). Child Clinical Psychology. Manual CEDE de Preparación PIR, 03. CEDE: Madrid.