Foreword I

A Pediatric Gastroenterologist’s Insights on Soiling Solutions®

By Audrey H. Birnbaum, MD
Mount Kisco, NY

It’s 9AM and I walk into my exam room finding a shy, cute 7 year old boy sitting on the exam table. His mother is there with him, but there is a third presence in the room also -- the distinct, unmistakable odor of old feces.  I know right away this boy is here to see me for encopresis (fecal soiling), but when I look on my intake sheet for the reason for the visit, his mother has only vaguely written “bowel problems.” I would venture to say that many of my Pediatric GI colleagues would not find this to be the high point of their day, but it doesn’t bother me at all. Besides being relatively “immune” to the scent of stool after over 20 years in practice, I actually relish the opportunity to help this child - because I already know his parents are extremely worried (and may have at one point been angry), I know he is quite ashamed, and there is a very good chance he has never been treated, or never properly treated for this condition. Lacking any proper humility, I boldly tell his mother that this is an entirely fixable problem that we should be able to resolve within weeks to months.

And this is actually true. The question at hand is how to successfully achieve that goal. Is it a fixable problem?  Absolutely.  No child has to go to school smelling of feces. And no parent or physician should give up treatment because the prescribed treatment has not worked and they do not have anything else to offer.

The standard of care in Pediatric Gastroenterology is very often successful. It is predicated on the following principles:  stool retention fills the colon (large intestine) making it flaccid and poorly functioning; an overfilled colon will lead to “leakage” due to “overflow;” a chronically filled rectum loses sensation of the urge to defecate; and keeping the bowels moving through artificial means will allow these processes to return to a normal state over a period of time. Not surprisingly then, treatment is aimed at each of these “malfunctions.” If the colon is first emptied, it will no longer be full of stool and the accidents should immediately cease. However, since the colon is still widened and flaccid, it must be kept emptied through the use of some type of laxative or stool softener. Okay, that makes sense too. Over a period of time, the colon and rectum should shrink and rectal sensation should return and … Voila! Problem solved!!!!

Well, I would venture to say that this method does often work.  And when I have seen failures, sometimes it is just a matter of an inadequate first step (the clean-out), or a poor choice of the second step (the laxative part), such as using a stool softener that make the stool too liquid and doesn’t provide an “urge” to defecate. But here is where we physicians fail miserably….What happens when we don’t achieve success? What do we recommend then?

I have heard some very disappointing stories at this point.  Families are often “dismissed” from the practice or told there is nothing more that the doctor can do. They may be sent for another opinion but it is really not for advice, but as a way of having the patient go away. They may be told to keep giving the laxatives or stool softeners despite constant soiling and to just wait for the child to outgrow the problem. Or they may be sent for psychotherapy to see if there is “something behavioral going on.”

Well, I can’t say I did much better. Until recently, I had no other avenue, no other place to turn for children whom I failed.  Repeat cleanouts, trying different laxatives, behavior modification, were the only tools we gastroenterologists had.  We have been taught NOTHING else. Of course we might do further testing if a child was not doing well, but the likelihood of finding a true medical problem was exceptionally low.

My turning point came when I was treating a patient whose mother was a colleague, a pediatrician whom I had known for many years. I was failing this child miserably and it was exceedingly embarrassing, to say the least. I felt a little vindicated when they moved to another state, went to a premiere Pediatric Gastroenterology program in Philadelphia, did a few tests (all negative) and also failed treatment. Frustrated but persistent, this mother found Soiling Solutions® on her own and within one or two weeks, her daughter’s problems were resolved. Even after I found out that she had used the Soiling Solutions® program, I was still resistant to even looking it up on the Web, dismissing it summarily because it was not a physician-supported program.  Skeptically, I gave in and eventually, realized that it made perfect sense, bought the manual, and was completely “sold” on the concept.

It was SO OBVIOUS where the problem lay. It was in the withholding itself! Those children who still withheld stool would clearly not respond to any amount of laxative you could give them. Fooled by the fact that these children, who were not toddlers anymore, did not refuse to sit on the toilet, I did not “get” that they might still be subconscious withholders. No, we doctors didn’t have a treatment for withholding, and neither did the psychotherapists.

The beauty of Soiling Solutions® from my perspective as a physician is that is the perfect bridge between the physical and the behavioral side of encopresis.  It is the only program I know that addresses both issues simultaneously. While Dr. Collins is working on reconditioning responses, he is also making sure that the child is defecating adequately EVERY DAY. A child who is doing this is not soiling. He does not smell. And his colon is shrinking and not retaining stool. So the goals and principles I had stated above (from a physiologic standpoint) are being met, while he is relearning how to do all the things required to go to the bathroom normally.

Since learning about the program, I have recommended it for numerous patients with universal success. My patients, some of whom struggled for years, have expressed tremendous gratitude, most of which I will redirect to Dr. Collins. Many of my patients have seen success within a matter of just a few weeks, even if they have struggled for years with encopresis.  Some of the patients have been teenagers involved in years of psychotherapy. No, I have not given up my standard treatment, which I believe still has its place. But Soiling Solutions® undoubtedly is a valid and extremely important treatment option for encopresis.

Finally, I would like to add that I have absolutely NO financial interest in Soiling Solutions®, so everything you may read here is an honest, from the heart, account. Those of you who are reading this most likely are already on your way to success, so to you, I say, congratulations for getting here!

Audrey Birnbaum, MD
Mount Kisco Medical Group
Mount Kisco, NY

FOREWORD II

A Mother and Clinical Social Worker’s Insights on Soiling Solutions®

By Eunice Lehmacher, LISW-CP
Seneca, SC

None of us would have picked Encopresis as a disease for our children. But now that I have gotten through it (with the help of Soiling Solutions®), I can see that our family and I benefited in many ways. I now have a child who likes eating salads and has a well-balanced diet (and is probably less likely to be obese or get heart disease). All of us appreciate our natural processes more, and our family has learned and practiced many ways to relax. We all learned that sometimes our schedules and priorities need to shift for another family member’s needs. My parenting skills have grown (e.g., I am more consistent, I am better at being firm, but loving.  I am not so easily manipulated. I have gotten to be quite good at behavioral training). My son has learned that I love him no matter what (come pee or poopy undies). I have read that enco kids are strong willed, and this certainly fits my son. I am glad to have gone through this battle of the wills young. He has learned that I will follow through no matter what and that when I do its part of my unconditional love for him.  And, he has even learned that he is better off because of it. Although I am not the mom of a teenager yet, I suspect the battle of the wills would have been nastier when he is 17 years old.

I cannot say that I am happy about all that time I spent in the bathroom and with the dirty laundry. But from a perspective of three years clean with most of the bad memories faded, I can say  that I am glad to have this 11 year old who has come through this crisis and is better for it. He no longer even needs reminders to poo. I have also learned that when I have a problem (even if it is an embarrassing problem), it is better for me to be open about it instead of being ashamed and secretive. The internet Soiling Solutions® forum provided me with a community who understood our problem and was encouraging. This process taught me that when I have the courage to talk about my problems, help comes. Being open about enco helped me to be open about other problems later, and to be more accepting of myself and my parenting.

At the beginning of this process, you are not ready to think of encopresis as something good that happened to your family.  But perhaps in two weeks, two months, or two years, you will realize that you and your child have grown immeasurably through this behavioral training. You will not enjoy all parts of the journey, but you will not regret doing Soiling Solutions®.  Dr. Collins' approach works for the poo and the development of your child. And as a nice bonus it will grow and support you as you parent.  I will “see” you soon on the forum.