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Encopresis or rectal incontinence is the repeated escape of the feces of a child 4 years or older in inappropriate places, such as clothing. It is often the result of chronic constipation, which over time results in fecal impaction and a leak resulting from accumulated liquid feces above the impacted feces. This leakage can occur during the day or night and is not under the conscious control of the child. The leak varies in frequency; It can vary from infrequent occurrences to an almost continuous flow.
- 1 Causes of Encopresis
- 2 Primary Encopresis
- 3 Secondary Encopresis
- 4 Areas of exploration in Encopresis
- 5 Treatment of Encopresis
Causes of Encopresis
Many times anal incontinence or encopresis can be caused by anatomical, neurological, endocrine, metabolic, post-surgical lesions, etc. This has to be ruled out by the child's doctor, usually the medical examination will be carried out following a routine more or less like this: medical history, physical examination that includes abdominal examination, perianal inspection and anorectal touch; blood tests, urine culture, radiographs, anorectal manometry and histological or histochemical studies that are performed from a rectal biopsy.
Two exists Types of encopresis: primary and secondary.
Yes it is primary we need to know what are the deficiencies in defecation and hygiene habits, in order to know what required behaviors have been learned and which have not. We also want to know how the evolutionary process has been in other areas of development (gait acquisition, language, autonomy skills ...), because if that were the case, we would face a general delay in development. You also have to ask the parents what method they used to train their children and the difficulties they have encountered or encounter in this type of teaching; with this we can discover inappropriate paternal behaviors, such as overpressing their children to defecate in the toilet at the times they want, without take physiological variables into consideration, or use abusive or inconsistent methods of punishment to control accidents.
If the encopresis is secondary, the interview is aimed at investigating personal, family and environmental conditions, associated with the beginning of fouling such as illness, the birth of a brother, separation from parents, beginning of schooling, avoidance of school restrooms; and with its current maintenance that may be different from the circumstances that caused it.
We also have to find out if encopresis is retentive or non-retentive, we know this by the presence or not of constipation. We asked about defecation, its frequency, difficulty in expelling, discomfort when defecating, presence of hard stool.
To identify the stimular situations that lead to retentive guidelines we do it by asking if the child complains of pain when defecating, if he shows any fear related to the bathroom that makes one suspect a phobia, if he usually "entertains" to go to! bathroom when you are doing activities that you like or if you resist going to the bathroom outside the house. You also have to find out if you are aware of the need to go to the bathroom or if you do not perceive the signs of rectal distention that precede defecation.
We also want to know what eating habits you have as chocolate abuse, cola, which is very normal for children to take and which is discouraged in case of constipation.
So, as we have seen, Encopresis can be primary if the child has never achieved complete bowel control; secondary when control has been acquired for a while and then lost. We must not forget the manipulative encopresis, less frequent, they are encopréticos that achieve an effective manipulation of their environment obtaining a series of advantages such as avoiding school, excessive attention of parents, etc. There is also chronic diarrhea or irritation syndrome in which defecation occurs as a reaction to environmental stress or emotional difficulties. And in the end the chronic constipation or Psychogenic Megacolon that usually leads to an exaggerated widening of the colon and constipation can be caused by organic or neurological factors that should be ruled out.
Once the type of encopresis is defined, it is necessary that we specify the problem according to the following behavioral parameters; frequency of encopritical episodes, consistency, quantity and size of stool in underwear, occurrence of night accidents, where the child gets dirty (at home, in the street, at school, etc.) and if he defecates, in addition to clothing, in other unconventional places such as on the ground, for example. Nighttime episodes are rare in functional encopresis; when they appear they usually give us an idea that we are facing an organic problem and have a worse prognosis than daytime. In this case, we have to make sure that the medical examination has been really good.
Finally we have to know if the episodes of encopresis increase in potentially stressful situations, such as family discussions or exam seasons, while decreasing during vacation periods and / or when the child resides outside the home for a season (with grandparents). We also ask about the social consequences that follow fouling, to know if they have a functional relationship with their decrease or maintenance; Parents are likely to scold and punish the episodes a lot without realizing that these attitudes have little effect on solving the problem.
At the end of this section of the evaluation we will continue to explore hygiene habits. The questions aim to evaluate the personal and environmental resources available to schedule the initial phase of the treatment, we will ask:
- The child's behavioral repertoire regarding: what are the current guidelines in the use of the bathroom, if you use it spontaneously only sometimes, if you avoid it totally or partially (only at school) or if you remain sitting for a short time, if you have appropriate cleaning habits to clean up after defecate, if you wash your hands, if you are autonomous in your personal hygiene, etc.
- The environmental conditions that favor or disturb access to the bathroom: bathrooms available in the house, number of people who can use them at the same time, easy access to the bathroom during school hours ...
- Morning customs of the family: raise the child with enough time to respond to their physiological needs, the usual sequence that the child performs in the morning, does he eat breakfast first or leave it for last?
The majority of the secondary encopréticos and good part of the primary ones sit down and defecate sometime in the toilet, this suggests that they perceive residual intestinal sensations. We have to find out what factors determine this behavior and why its frequency does not increase.
You have to ask the child about his own habits, to explain what drives him to go to the bathroom, what he feels before starting this behavior, what he does when he sits in the toilet to defecate, how he executes the thrust efforts, how long he stays seated…
Later we have to find out if other problems concur while encopresis. We also need to know the repercussions that encopresis has caused and causes in the family context in the school environment and in the child himself, as well as the means used to address the problem. It is also important how the child behaves when he becomes dirty, if he hides the clothes, if he changes when asked, if he shows indifference and remains dirty until he is forced to clean himself, or if he shows himself cooperative and tries to resolve the incident. soon as possible. Finally ask about the impact of encopresis in school, which is normal that they do not even know.
We will obtain information about previous treatments and try to find out why they failed, so we will avoid using techniques that have proven ineffective and will control the factors that interfered with the success.
We have to explore the degree of motivation of parents and children to correct encopresis and identify possible positive reinforcers that could be used to increase or maintain objective behaviors. As with enuresis, one of the most frequent reasons for treatment failure is that the therapeutic instructions are not followed. The support, close supervision and accessibility of the therapist in times of discouragement will help to maintain a better cooperation.
Areas of exploration in Encopresis
1. History of encopresis
a) Identify the type of encopresis:
- Start of encopresis
- Learning disabilities in defecation and hygiene habits
- Delay in other areas of development
- Precipitating events and maintenance factors
- Frequency depositions and other data that reveal constipation.
- Stimular conditions that generate retention patterns
- Diet and physical exercise
b) Delimit the problem behavior:
- Frequency episodes of encopresis
- Consistency, quantity and size of stool
- Day and night episodes
- Soiling out of underwear
- Where accidents occur
- Fouling awareness
- Circumstances that modify the frequency
- Problem duration
2. Hygienic habits: behavioral repertoire and environmental conditions
Spontaneous defecation in the toilet:
- Frequency, consistency, quantity and size of stool.
- Time you dedicate to this activity
- Total or partial avoidance of toilet use
- Environmental conditions to access the bathroom
- Morning routines before going to school
- Habits of personal hygiene and degree of autonomy
3. Concurrent problems
- Signs of anxiety or depression (sadness, isolation)
- Attention deficit / hyperactivity
- Opposition and disobedience behaviors
- Difficulties in academic performance
4. Family, personal and school impact: ways of coping
- Parental reaction to the problem
- Reaction of the child; hide dirty clothes, cooperate
- Peer reaction: rejection, mockery, marginalization
5. Previous treatments
6. Motivational factors
As an explanation for bedwetting we can say that constipation plays a primary role. If constipation persists and an evacuation does not occur, hardened and clogged stool presses the intestine to the point of causing widening in the colon and loss of muscle tone, The fluid material coming from the small intestine reaches the bulk and having no space to be absorbed due to the obstruction, it leaks through the retained feces and stains the clothes, so that children are not aware of the need to defecate .
Finally to be able to perform the functional analysis we will make records of the episodes where we must include date, place where it poops, time, type of stool, quantity, size, what others do or say and what the child does or says.
For the evaluation we will register for a week or if possible for two. If with this we are not clear about the information, we will continue to ask you to fill in the records.
Vessel defecation is the last link in a complex behavioral chain: discriminating physiological signals that precede defecation, retaining feces in response to this stimulation until the right place is found, undressing, sitting in the toilet, and once seated relax the external sphincter to allow feces to go outside. So it is necessary to determine if the child has learned the complete sequence to be able to decide which behaviors should be enshrined, which ones need to increase their frequency and which ones should decrease. Even if the entire chain is learned, it is still possible that the fouling of the underwear is simply because it does not know how to clean properly. The excess or deficit of any of the responses that make up the behavioral repertoire can lead to episodes of encopresis; contracting the sphincter the time necessary to reach the bathroom is the relevant response, but this action is prolonged. if necessary, the defecation sequence is interrupted and can lead to a series of known problems: fecal retention, constipation, muscle or sensory deterioration and, finally, fouling.
Before starting the treatment if we have discovered problems such as a bathroom phobia or shame to use the school bathroom, we will have to treat it first and only then begin the exclusive treatment of encopresis.
We will begin the treatment explaining to the child, in the first session of therapy, what the functioning of the digestive system consists of, for this we will use drawings (type of school book) and we will go teaching the parts of the system, then we will pass to explain to him what encopresis is, what is happening to him and that there are many children who are the same and that maybe in his class there is someone else who is the same, but that people usually shut up And he doesn't tell anyone. We also have to try to take personal importance from the problem, forgive him and tell him that what happens to him has a solution and that until now he had not been able to avoid it because he did not realize what he was doing and did not know how to achieve it. We tell you that we are here to help you on this issue, but that we cannot do it alone and that we need all your collaboration to achieve it. We ask him if he wants to stop staining clothes and we ask him to tell us how he feels when he stains or when his parents tell him that it smells bad, that he is a piggy and that he is going to change. This gives us an idea of how far he can be motivated now that he knows the details of the problem and has already passed an evaluation. We try that verbalize your desire to be well and say the good things you would get by stopping staining clothes. We are going to dedicate this entire session to teaching her physiological responses about defecation, teaching her what the problem is and encouraging her to seek change using us as mediators.
In the second intervention session we will work with him we will explain that you have to look at the sensations before defecation, that you have to be aware of them, that those feelings that you described in the evaluation process (pain in the gut, tingling in the stomach, pressing sensations of not holding it anymore.) You have to look closely at them when you have them again and you have to write on a paper what you notice in your body (this you have to bring the next day see you later) Then we will explain how the behavioral chain they have to appear when they feel those "desires": we tell them to contract the anal sphincter (for this they have to practice in front of us in this session, we verify that they do well if sitting in the chair , when contracting the sphincter, it rises a little in the seat) and look for the nearest bathroom, once there you should sit and defecate, clean yourself checking that there is no rest and wash your hands afterwards.
We will do the anal sphincter tension tests first, and then we will practice in other postures such as standing or running. We will do it in all the situations that the evaluation gives us and that we have seen that the child cannot by himself control and ends up taking place the dirtying.
We will continue to encourage you to solve the problem and praise your efforts to achieve it.. We will end this session by reminding you that the next day you have to bring us the sensations you feel before going to the bathroom (the "desire"), with great detail.
In the third session we are going to ask you to return to the parents, the three of them will come to the office and we will explain that it is necessary to know the things that we can use as reinforcement in therapy. We explain that we are going to use a system in which the child will put a sticker in his register every time he poops in the toilet, the more times a day he does it, the more stickers he will get. These stickers will have a value (points) that will later be exchanged for the reinforcements that we have selected and to which we will have given a value. To get a boost you will need a series of points. It is very important to develop the list of reinforcers with the parents and the child and that they help us put the score. We should never include as reinforcers things that the child is usually getting for nothing. If we do this instead of reinforcing, we will punish. If, for example, the child always sees the Simpsons, we cannot include "see the Simpsons" in the list; we will have to put small surprise gifts, be able to go to the cinema one day in particular, choose a trinket in a store, go to the amusement park one day, choose the movie that the whole family will see that night and in general all the things that he wants the child and can give him the parents, but always of little value and with commitment on the part of the parents to exchange it when the child requires it. The points will be written down in a notebook or in the same register and the parent that we see better able to carry the encopresis will be in charge of giving the points and their subsequent redemption.
We will ask the Parents who praise the child with praise whenever you poop in the toilet and ignore when you stain your clothes, just be told to change your clothes and wash, but do not make reproach gestures or use phrases that can show your discomfort with the situation, it is about That the child understands that if he poops in the toilet his parents will be very happy and if nothing.
In the registration of stickers or dots you will not be penalized at any time for stained clothing; that is, if the child does not poop in the toilet all day and does it several times over it simply will not put any sticker on his record; but if he poops once in the toilet he already earns a sticker with his corresponding points.
When we have the reinforcers and the values given we will remind you to launch everything we have asked you for this session and bring us the registration next day.
In the next session the parents also have to enter, we talk with them about how points have been obtained and we explain that it is necessary to establish a routine with a well structured sequence. We will ask that every morning you wake up the child half an hour in advance of what they were doing, that the child should wash, dress and have breakfast and then sit in the toilet to try to defecate, if he gets it he will earn twice as many points as he does. at any other time of the day. But during the day if you feel like it again, even if you have defecated in the morning you should continue going to the bathroom, putting into practice what we had tested for anal sphincter contraction. At noon after lunch, you have to sit in the bathroom too and at night you have to perform another routine that will consist of picking up the study books, preparing the backpack for the next day (on school days), preparing clothes for The next day, put on your pajamas and have dinner, then you must go to the bathroom and try to poop, if you get it, as before, you will earn twice as many points as at any other time of the day.
Is routine has to be fulfilled. The time that the child must remain in the toilet trying to poop should be around 20 minutes, during this time and so that it is not aversive, or a punishment, you can listen to music if you want; Read comics, draw, or whatever. Before pulling the chain, you must notify the person in charge to see what you have done, not in order to control whether or not you have done it; if not so you can reinforce continually.
This what we will keep all the necessary time until the change occurs. We have to be especially attentive to the reinforcers since they will be the ones who help us in the first moments to establish the new behavior; But there may come a time when they lose their reinforcing character and we should be reviewing the list weekly to remove and insert reinforcers when necessary.
The treatment ends by achieving two consecutive weeks in which there is at least one daily deposition in the toilet and no deposition in the clothes.
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