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Management of encopresis and the parents' role

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VOL: 97, ISSUE: 20, PAGE NO: 55

Maeve McGinley, BSc, RGN, DipN, DNCert, is continence adviser, Foyle Health and Social Services Trust, Londonderry

Encopresis is a common disabling condition that causes loss of self-esteem in children and conflict in families, and places a heavy burden on health care resources.

The term was first defined by Weissenberg in 1929 as ‘the passage of a normal stool in an unacceptable place’ (cited by Buchanan and Clayden, 1992). This definition was broadened in the USA to include soiling. Levine (1975) used the term to describe any child over four years of age who regularly passed formed, semiformed or liquid stools into his or her clothing with no apparent primary organic aetiology.

By contrast, in the UK Clayden and Agnarsson (1991) used separate definitions for encopresis and soiling. They described encopresis as the ‘passage of a normal stool in socially inappropriate places (including clothing)’, and soiling as the ‘involuntary passage of fluid or semisolid stool into the clothing (usually as a result of overflow from a faecally loaded rectum)’.

Bellman (1966) suggested that encopresis was generally defined as repeated voluntary evacuation of faeces in the clothing without there being any gross explanatory cause, but this does not appear to be a universally accepted definition.

This lack of agreement has led to variations in the reported prevalence of encopresis and problems in formulating subclassifications.

Blackwell (1998) warned that definitions of encopresis could be unhelpful in that they separated children into medical or psychiatric treatment groups. Research studies have indicated that such segregation can reduce the chance of successful treatment and that multifaceted approaches appear to be more effective (Elliet, 1990; Levine and Bakow, 1976).

Prevalence

There is little up-to-date data on encopresis prevalence, but Bellman (1966) estimated it to be 2.2% in five-year-olds and 1.5% in seven-year-olds. Rutter et al (1970) found prevalence rates of 1.2% in 10 to 12-year-old boys and 0.3% in 10 to 12-year-old girls.

Buchanan and Clayden (1992) believed Bellman’s figures to be an underestimate, as only 15 of 132 children identified in the study actually had the problem recorded in school records. Encopresis was found by Fritz and Armbrust (1982) to be four times more common in boys than in girls.

Classification

Clinicians have attempted to develop classification schemes for encopresis to be used as guides for treatment routes. This has proved difficult because of the disorder’s diverse aetiology. Two of the most commonly used subtypes in the literature are primary versus secondary, and non-retentive versus retentive encopresis.

Children with primary encopresis have reached four years of age without being continent for at least one year. Those with secondary encopresis have shown independent bowel control for at least one year (Howe and Walker, 1992).

Non-retentive encopresis is defined as the child voluntarily passing a normal stool in the clothing inappropriately (Sprague-McRae et al, 1993). Retentive encopresis is characterised by involuntary leakage of faecal material as a consequence of chronic constipation and stool impaction (Levine, 1975).

Retentive encopresis

Retentive encopresis has been identified as the most common type of this disorder (Clayden and Agnarsson, 1991). Levine (1975) estimated that it accounts for 80% of all encopresis cases.

The key aetiological factor is constipation, which can result from a number of causes, including:

- Environmental factors: for example, food intolerance, inadequate fibre or fluid intake, ignoring physiological cues to use the toilet while at school or engrossed in activities, or taking certain medications;

- Physiological factors: for example, neurological disorders, Hirschsprung’s disease, congenital megarectum, anal stricture or anal abnormalities;

- Psychological factors: for example, withholding bowel movements during coercive toilet training, fear of defecation or over-anxious parenting (Stark et al, 1997).

If a child repeatedly fails to empty his or her bowel, constipation will develop. The rectum will become loaded with an increasing mass of faeces, causing distension of the colon, a reduction in muscle tone and retention of stool. The child’s ability to detect the urge to defecate will diminish as muscle tone decreases. The longer the stool remains in the rectum, the more water is removed, so impaction occurs. The stool is then difficult and painful to pass, and the child becomes reluctant to defecate.

As distension of the rectum and colon continues, faecal material accumulates behind the impacted mass. A reflex dilation of the anus then occurs, allowing faecal liquid - from behind the mass - to involuntary leak out, causing soiling. Once the problem begins, a cyclical pattern of constipation, retention, overflow/soiling can develop. This can be maintained by the child avoiding large or painful bowel movements, attempts to assert independence or insensitivity to stool in the colon.

Treatment of retentive encopresis

The wide range of treatments reflects the complex nature of encopresis and the difficulty in agreeing on subclassifications. Treatments include one or a combination of the following: cathartics, medications, dietary alterations, biofeedback, behavioural programmes, psychotherapy and hospitalisation (Howe and Walker, 1992).

The wide range of treatments prompts two key questions: first, how is a child with encopresis assigned to any one or a combination of these treatments; and, second, which treatments are most effective?

In the past, there was a tendency to use subclassifications to assign children to different treatment routes. For example, a child diagnosed as having ‘retentive’ encopresis was classified as having a physical problem - constipation - that required a medical treatment approach. This involved evacuation of the bowel, so the child would be referred to a paediatrician. By contrast, a child with ‘non-retentive’ encopresis was classified as having a problem that was psychogenic in origin and required a psychotherapeutic approach, so a referral to a psychiatrist would be made.

Clayden (1976) and Levine (1975) argued that, in practice, it was difficult to separate children with soiling problems into such distinct groups. Buchanan and Clayden (1992) suggested that most children who soiled probably fell somewhere along a continuum and had varying degrees of physical and emotional problems that were neither primary nor secondary to the problem. Treatment programmes therefore needed to be tailored to the specific needs of the individual child. Chaney (1995) recommends the development of a collaborative protocol for the successful management of encopresis, of which communication is the basic component (Fig 1).

A long-term follow-up study of the treatment outcomes of 45 cases of encopresis found that with time it was increasingly likely that a child with encopresis would achieve remission (Rockney et al 1996). As a study has not been done to assess the rate of spontaneous remission for encopresis, it remains uncertain whether remission over time is the result of previous treatment or the natural history of the condition.

Studies evaluating the efficacy of treatments therefore need to be controlled if the value of the treatment is to be judged objectively. Further definitions of success can range from complete remission to improvements in the child or carer’s psychological well-being, depending on the treatment.

Studies of treatment efficacy for encopresis appear limited in a number of ways. They are few in number, few are controlled or use random sampling, and sample sizes are often small and sometimes based on individual case studies (Thapar et al, 1992). This, understandably, makes evaluation on an empirical basis difficult.

For the purposes of discussion in this article, treatments will be divided into the following groups:

- Psychotherapy;

- Behavioural programmes;

- Biofeedback;

- Medical;

- Mixed and multimodal treatments.

Psychotherapy

The psychotherapy approach to encopresis focuses on resolving conflict in the child or parent rather than focusing on evacuation of the bowel. The approach includes psychotherapy, play therapy and family therapy, but few studies have evaluated its effectiveness. Howe and Walker (1992) felt this approach was not proven to be effective.

There is a need for clinicians to evaluate parents’ attitudes and insights, but also to provide education and support to parents as part of the treatment. In recognition of this, Foyle Health and Social Services Trust is compiling a booklet to help parents understand encopresis and its management (see box overleaf).

Behavioural treatment

The primary focus of behavioural treatment is to reinforce appropriate behaviour and to mildly punish soiling or inappropriate toileting behaviour by the child. This approach is used widely.

However, studies of its efficacy are few and their design is limited. Much of the research has been based on single cases or small sample studies, but the results have been positive. The strategies used have involved periodic pants checks, regular toileting and positive reinforcement (reward systems), and cleanliness training.

Behavioural treatment combined with regular toileting can be effective in managing encopresis. The emphasis of rewards needs to focus on appropriate defecation rather than cleanliness, otherwise the child may withhold stools (Thapar et al, 1992).

Biofeedback

Interest and support for the use of biofeedback as a treatment option has increased. In a randomised control study of 50 children, Wald et al (1987) compared biofeedback with the use of mineral oil. Overall, the outcome appeared similar for both therapies, but children with abnormal defecation dynamics in the biofeedback groups showed much greater improvement.

As this is an invasive procedure, for example, a pressure-sensitive device may be inserted into the rectum, it should be used only when other treatments have failed (Olness et al, 1980). It remains uncertain which aspect of this therapy has greatest effect.

Medical treatments

Medical treatments for retentive encopresis include dietary changes, exercise and the use of cathartics (Howe and Walker, 1992). The aim is to clear the bowel and produce regularity in bowel movements. A follow-up study, in which laxatives and mineral oil were used as treatments, found that 47% of subjects were symptom free and a further 30% had their symptoms controlled through continued use of laxatives (Howe and Walker, 1992).

Clayden and Agnarsson (1991) suggested that with long-term laxative therapy, compliance can be a problem. And Blackwell (1998) has warned that the use of enemas and suppositories is controversial and, from a psychological prospective, the less invasive the procedure the better.

Although diet is an important aspect in the management of encopresis, there appears to be a lack of studies to support this. However, the need to increase consumption of dietary fibre, decrease consumption of dairy products and maintain a high fluid intake has been advised (Plyes and Gray, 1997).

Failure rates of 20% to 40% have been reported for the medical approach (Levine, 1975). However, bowel evacuation as a first step in treatment is supported in the literature. The use of enemas should be limited to when no other cathartic is effective.

Mixed and multimodal treatments

Mixed or multimodal treatments combine medical and behavioural techniques. The approach works on the premise that the bowel must be evacuated before behavioural control of defecation can be established. The basic components of the approach are:

- Educating parents and children about the development of encopresis;

- Physiologically eliminating constipation;

- Initiating a programme to encourage appropriate toileting behaviours (Chaney, 1995).

In Levine’s study (1975), a multimodal approach was used to treat 102 children with encopresis. Education involved explaining bowel function and placing the emphasis on reducing blame. At follow-up, a 70% success rate was reported.

Van der Plas (1997) studied the role of education, demystification and toilet training in children with encopresis. Fifty-nine children and parents each underwent an educational session involving verbal explanation reinforced by written information. At follow-up, 15% of children were symptom free. Although the different aspects of the approach cannot be separated from one another, it indicates how demystification can have a positive outcome in treatment.

Papenfus (1998) supported the view that verbal information given to children with encopresis and their parents needed to be reinforced in written form, so the child, parent or teacher can read it. Demystification and written materials are evidently an important factor in successful treatment outcome and compliance (Sprague-McRae et al, 1993).

Stark et al (1997) reported an 86% cessation of soiling rate in a study that combined medical and behavioural therapies and used group treatment sessions. Given the heavy demand placed on resources in managing encopresis, group education sessions offer a cost-effective treatment. Buchanan and Clayden (1992) reported that a ‘whole child approach’, involving empowering the child, demystification, treating the child in a community setting and physical treatments, was most effective in the long-term.

The multimodal approach appears to be the most effective treatment. Demystification is a key element in its effectiveness. It gives the child a sense of control over the problem and helps parents to adopt a non-accusatory and supportive role, which increases motivation and decreases non-compliance in the child.

Conclusion

Encopresis is a common disabling condition that causes loss of self-esteem in children and conflict in families, and places a heavy burden on health care resources.

A multimodal approach to treatment - for retentive encopresis - has been identified as being the most effective. Making it work requires collaboration between all those involved. Education is a key element in a successful outcome. We hope that the provision of a booklet for parents of children with encopresis will improve the quality of care at the trust’s encopresis clinic.

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