A New York mom whose youngest of 6 children (6 yrs., 7 mo. old) is a “holder” and has been getting worse over the past year.
February 3, 2012

Question:

My son is the youngest of 6 kids. He has had problems with constipation, fecal impaction, and Encopresis. I believe we have the constipation under control with Miralax for the past 2 years. I have worked very hard trying to toilet train him with a toileting schedule, positive reinforcement, diet, etc. He seemed to be more trained a year ago! I am soooo frustrated. Over the last year, he has gone way downhill and does not go on toilet at all anymore. He is soiling 3-4xs a day and is perfectly happy to sit in it, even overnight. I have worked with a PedGI and pediatrician but things are getting worse. He holds it at school and at  friends’ houses. He is developmentally normal in every other way. PLEASE HELP!

Dr. Collins’ Answer:

The waxing and waning and relapsing for Encopresis are really fairly common. These children are just very vulnerable under stress, changes, vacations, etc. etc. to relapsing.  Reasoning has little effect with the very heavy denial and “shutting down” that these children go through. Some of the older children actually go into a trance-like state known as disassociation if you talk to them about it. You are very heroic with 6 kids!!! I think that you have maxed out your current approach and will have to try biofeedback or my program. 

Very briefly, biofeedback can occur in two forms. The best researched method involves manometry or pressure readings. A balloon is inserted into the rectum to take pressure readings as it is filled until the child begins to recognize filling sensations.  This can be done until the child recognizes the filling sensation at lower and lower pressure values. The child then is also asked to expel the balloon so that you are conditioning both sensory and motor skills. This requires an advanced medical setting. The other form is to record muscle tension using surface sensors (electromyography or EMG) and a dual channel display so that the subject can see the relative activation and relaxation of the muscles involved in a more coordinated action for successful bowel movements. My impression is that this is being done more often by physical therapists in their office or clinic settings.

My Soiling Solutions® (SS) protocol has the advantage of being conducted strictly in the home for just one hour a day using carefully sequenced suppositories and enemas (S&E) with very brief sits to assure a daily bowel movement which conditions proper sensory recognition and proper muscle coordination. Most parents and doctors have no idea of the different versions of S&E which must be utilized in a taper toward the child’s own takeover of his bowel movements. All of this is covered in the Clean Kid Manual© (CKM) and there is a lot of insight and support offered by a very active SS Parents email community which comes with your order from the store at www.encopresis.com.

I recommend that you see a PedGI, Audrey Birnbaum, MD, in Mount. Kisco, New York. She wrote a foreword for my latest revised manual, which you can see under the Clean Kid Manual© menu tab on this website. We see remarkable positive changes in the children and families as much tension and conflict is removed. The children just absolutely flower as they emerge from months and even years of failure.

A Canadian dad with a 7 year - 4 mo. old daughter who has defied five years of treatment for a holding form of Encopresis, despite the best medical treatment and their own reinforcement efforts.
January 31, 2012

Question:

My daughter has been holding her poop since she was 2 1/2 years. She says she's afraid it hurts even though it hasn't hurt since probably she was 2 1/2. She will hold it sometimes for 3-4 days before finally letting it go. When she does, my wife and I show true excitement and give her lots of attention and reinforcement, but nothing is working. We've been giving her PEG (Polyethylene Glycol) for the last year, and it hasn't helped. Sometimes her breath stinks of waste, and we're so worried it's becoming toxic to her body. All our doctor will tell us is to keep trying the PEG. It's not working!!! We're frustrated, scared, and at the end of rope. We've tried using a chart with a treat after every 5th time she pooped. We've tried other treats such as movies, etc. We're out of ideas and hope. Please help.

Dr. Collins Answer:

When parents write in by completing the questionnaire for this column I provide as immediate an answer as I can, but then follow up with a more edited and complete response on a future Tuesday or Friday date. 

Five years of holding with no solution! Your docs are not addressing the holding issue directly which must be done. This is often the case. Maybe it is because it is a behavior? Read the foreword by a PedGI at www.encopresis.com under The Clean Kid Manual© (CKM) menu tab.  She deals with the holding response and notes how this lack of attention by her colleagues is overcome by my Soiling Solutions® protocol. You will need to purchase my CKM and follow the structure of the daily treatment hour very faithfully to best address the holding habit which is sabotaging your daughter’s recovery. I would prefer to have a physician standing by, but it does not sound like you have one that would be “open” to my bottoms up approach. This surprises me because the bottom is where the problem occurs, not at the top or beginning of the GI Tract. Yes, the lips are the beginning of that very, very long tube—some 33 feet in the adult! You can do the treatment using my manual and the parents’ forum which will be made available to you after you order the manual. You may wind up educating them, but be gentle they do have egos, sometimes enormous ones (as do I)! My manual does address approaching a monitoring physician who has to agree not to alter the treatment hour instructions. Read this Q&A column and lots of other information at www.encopresis.com. 

Oh, a final point, some children do not really respond well to effusive praise.  It may be calling too much attention to their problem and failure to conquer it. Tension tends then to interfere with the subtle muscle coordination issues with this problem. It also affects the activity of the GI tract itself. Believe me I often find myself cringing when I hear the all too frequent simple answers proposed for this problem.

Thanks for the question and background. It will help other inquiring parents to follow this website and be more informed about encopresis.

A New Jersey mother needs help with her seven-year-old’s Encopresis, but cannot afford the Clean Kid Manual© (CKM).
January 27, 2012

Question:

My son, now seven years old, has had Encopresis since age five years old. He started on the first day of school which ends in June and starts again in September. I have seen every doctor neurologist and psychologist  I am at a loss because he admits he is holding it in, I cannot afford your book, but would appreciate any advice. I am so worried, this has going on for three years now. Thank you for any help that you can provide.

Dr. Collins’ Answer:

My heart goes out to you and your son. It certainly sounds like you have already gone to some major expense and effort. I have worked on and explored treatment for this problem and bedwetting for over 35 years. Encopresis is by far the most despairing and isolating problem for children and their families that I have dealt with. It appears to be so fixable and yet defies so much intuition and common sense. Even physicians or psychologists from each of their exclusive perspectives cannot get a good handle on it. The CKM and its sale over the internet since 1998 was my solution for an inexpensive and effective intervention that can be done at home. Perhaps your school social worker or a case worker (county health department, etc.) could assist by ordering a copy of the manual at a discounted professional rate and employ it for you and other families. I wish I could give my manuals away, but perhaps one of your physicians could order it? I would be happy to consult with him/her at no charge.

Your son presents a very clear cut pattern with the school and summer vacation periods! But, no real surprise—the second most common onset of Encopresis is when a child goes to preschool or school for the first time. Another observation I have is that these children hold their bowel movements during the school period, but then “rebound” and have accidents toward the end of the school day. Also, we frequently see relapses for these children over vacation breaks, summers, and school periods, so your child fits in there. A lot here has to do with the lack of privacy in school lavatories (campgrounds, etc.) and especially those without doors on the stalls. 

The child’s “holding” habit becomes too strong and then may take a while to “untangle” and go back to a natural hold-release-bowel movement sequence.  Basically, the proper coordination for a complete and successful bowel movement has to be retrained. The term dysnergia is now used to describe this in top medical circles. OK, this explanation really does not tell you what you can practically do. So that is why I wrote an entire book to guide parents. I cannot tell you here everything you need to know and do in an answer for this column. Too many parents think that there is some simple secret diet ingredient, technique, or magic words for your child that will lead to a cure forever—sorry, that won’t happen. I would not want to mislead you. Encopresis is a very nasty condition and can take a long time to conquer even with my protocol, but the soiling stops very early and changes lives up front as treatment continues under much better and encouraging conditions. The colon takes time to return to normal, if it ever does.

If you can never find access to my manual, do consider the forum at www.encopresis_kids@yahoogroups.com. It is an active forum with support and advice among the subscribing parents.  It is not the SS Parents’ Forum.

A UK mum with a relapsing 7-year-old who is not having complete bowel movements.
January 24, 2012

Question:

My son soils his underwear 4 times minimum, 8 times max, a day. It isn’t a full number 2, but enough to cause his bottom to be wet. His underwear is generally thick with dried faeces. A couple of years ago he was holding his number 2 in at school, but only recently has he started soiling again. Dr. Collins, it’s not a full poo, can you advise?

Dr. Collins’ Answer:

Holding at starting school is the #2 most common event associated with the onset of Encopresis, so it is no real surprise here. Relapses often occur with the onset of school in the fall or the start of Christmas vacation for those children vulnerable to dysnergia (dyscoordination of the pooping muscles). He is backing up from poor coordination of holding vs. releasing his stool on the toilet. The normal sequence of voiding cue recognition, holding, and then releasing his stool is all scrambled. We see kids who think that they are working hard to void, tightening up their pelvic floor and the anal sphincter all at the same time! Their body is fighting them! You cannot explain it to them, it is too automatic and you don’t have the language to instruct or describe it. Even if they begin to release, they then tighten or cut off the bowel movement too soon.  So what you are seeing is leakage which can occur because of the additional pressure which he cannot withstand when coughing, sneezing, running, postural changes, passing gas, etc. Basically he has to be retrained for a complete and timely BM repeatedly on the toilet stool until it becomes a well-established coordinated act. That means biofeedback or my Soiling Solutions® program (see my November 22 Q&A response). 

The advantage of SS is that it can all be done in the home and you would have the advice and support now of over 650 parents on the exclusive SS parents’ forum. Non-SS parents are not allowed on the forum as they do not have the common base and orientation to encopresis which is conveyed by the Clean Kid Manual©. They would frustrate the parents who have purchased the manual and it would take too much effort and time to “catch them up.” They would also not have the necessary understanding and orientation which is necessary to succeed. The manual is far cheaper than ruined clothing, family tension, and repeated co-pays. Glad to hear from over the pond.

A California mother has a “resistant” 15-year-old boy and a tough question about the Clean Kid Manual© (CKM).
01/20/2012

Question:

Our son has had chronic Encopresis all his life, off and on. We have been to doctors, with the usual response. Will your manual and S&E treatments work for someone his age? He refuses to discuss the subject anymore and of course would not want anyone in the bathroom with him. We thought by the time he entered high school the problem would be resolved, but it's not, and in fact has recently seemed worse. Is there a doctor in our area that you would recommend who uses your protocol, and is it too late to try to use your manual with a resistant 15-year-old?

Dr. Collins’ Answer:

What I love about moms is that they hang in there for their children all the way. Easily, 95% of the mothers on the Soiling Solutions® Parents Forum are “Mama Bears.” 

The CKM will most likely work for this mother, but the big issue is:  Can her son “buy in” to the SS protocol so that he can largely manage it himself? Can he give mom or/and dad permission to supervise or at least remind him of each step in the protocol during the daily treatment hour? The manual is quite persuasive and dramatically different from anything that has been tried before with a much greater chance of success. You can read portions to him, leave it out on the coffee table, or have a dramatic family meeting including dad and citing portions of it that may get through to him. 

You will wonder why you have not been advised better before, but this is also a culturally taboo area involving a highly private area with a terrible body product, germs, smell, shame, etc.) which accounts for even physician reluctance. He can learn to self-administer the required suppositories and enemas and brief sits required during the treatment hour. The CKM does specify possible alternatives to the enema step which could make the protocol easier for some families. However, you will still have to be a supervisor or enforcer for assuring compliance. Even older mature kids will act against their own best interests with this disorder. There are other parents on the forum with older kids. The fact that there are other teen-agers on the list may help him feel less isolated. You will have to be strong and resourceful, but you will have lots of support and advice from the other parents who have been there. Back in the archives you will see the wonderful story of a 15 year old girl who responded well with a very strong and empathic mother.

If this condition continues to go unchecked he may wind up with an incompetent colon and require a colorectal surgeon for a resection or what is called a Malone-ACE procedure. Dr. Marc Levitt, a colorectal surgeon at Cincinnati Children’s Hospital, can sometimes avoid this with an intense week long procedure getting a child over onto a daily schedule of stool softeners and Ex-lax or daily enemas with daily X-rays. This is precisely why I have become more outspoken about SS as I have encountered severe and long-lasting cases of Encopresis. If SS fails then Dr. Levitt’s program options may be required. I mentioned other options in the November 22 Q&A, but SS is the only one that can be carried out in the home. Sorry, I have no referrals for your area.

Question:

Initial toilet training started just before 3rd birthday was successful with few accidents. About a month after I went away for 4 days and during that time she started pooing in her undies. It's now been 2 months and she refuses to poo on the toilet. If she is left with no undies on she just holds on likewise when her preschool put a nappy on for nap time she also holds on. If you talk about pooing on the toilet she will not go that day and hold on. My childhood nurse has advised to just ignore the problem and that she will come around once the pressure to poo on the toilet is removed...however I am not so sure. It’s been 2 months now she has been complaining of tummy pains a lot. My daughter likes to hide in her bedroom to go and gets very distressed if walk in whilst she is going. She normally goes every day in the afternoon along as she is at home and relaxed. If she holds on I generally make sure we are home the next day and basically wait till she goes. She has never held longer then one day provided we are home. My question is should I be intervening now and forcing her to sit on the toilet for poos or just waiting till she decides to use the toilet for poos. She is a very stubborn, smart and strong willed child...everyone tells me to just relax and not to pressure her, but I worry that the longer this goes on that habit of pooing in her undies will be further ingrained. From reading your website, I am not convinced that the top end approach will help as we have a holding issue primarily. Could I go straight to our solution?

Dr. Collins’ Answer:

Here is the initial response I made to this mother:

From what you describe, I think my protocol would be a very good idea to end months and possibly future years of unhappiness for you both. This is where a parent becomes very necessary with your more mature and long-term outlook—however smart she is she lacks that. Your question is important and I will put up a longer response on or about January 17, 2011

That very same day of my receiving this mother’s question, I received this email from another mother of a very young child which I shared with her:

"I am sure you get a lot of thank you letters, but I wanted to send you one anyway. Our son just turned 3 1/2, but was fully potty trained for a few months, before he started holding in his poop for about the past 4 months (since he started Nursery). He has suffered a lot since August, and so have we as a family. I tried your program out (with a bit of flexibility because he is so young), and it has worked in less than a week. He has pooped on his own for a few days now without any suppositories. This is a great program, and I do not feel that suppositories are traumatic at all. I don't understand why pediatricians are so against it. It is so much more traumatic for these children to be so fearful of going to the toilet, and of feeling horrible physically and psychologically for long periods of time holding in their poop. He is eating again and is so much happier and confident. He had a bad time in school for a few months, and now is happy to go. Your program is very important, and I hope that more pediatricians become educated and use it as a option for their patients."

The Clean Kid Manual© was sent to the Australian mother on 12/30/2011 and she was added to the SS forum the same day.  The SS forum currently has over 650 parents and 95 percent of them are mothers. I asked her on January 13 what was happening. Her response was very long so I will have to pick out some quotes by her:

"The Forum is such a fantastic resource and I have so much empathy for all the families who are dealing with this issue. The support given by everyone participating on the Forum is amazing to see and the wealth of knowledge from trial and error is invaluable. I have learnt so much from all that reading and certainly gained confidence that this issue was treatable...especially as my daughter is so young and the holding has only been going on for a short time."

"…she was holding so much we had to give her a suppository which she would hold until she was asleep and then would scream as she voided in her nappy whilst asleep."

"Even after the problems with my eldest daughter, I had no idea that this problem had a name and how many people were dealing with what looked like a long term problem. My husband was initially quite against the protocol when I explained the basic outline andwe argued about how to move forward...he did agree though that we did need to take some sort of action."

"Whilst waiting for my manual and after doing lots of reading of the archives I decided that I would put into practice some of the suggestions on the Forum. I also went and saw my family Doctor who wanted me to try the Top down approach for a few weeks to see if the issue resolved itself quickly. My husband agreed that if this did not work he would support trying SS."

In conclusion this Australian mother noted:

"Whilst I have not had to introduce the protocol as such, I felt the information I gained from the Forum and the Manual gave me the tools I needed to deal with this problem which, up until recently, was leaving me feel depressed and overwhelmed. I felt confident knowing if my initial approach, which included lots of tips from the manual and the Forum didn’t work, SS was there and I would not hesitate to implement if necessary.

Final Note:  Notice all of the initiative taken by this mother to protect and care for her child. Mothers are THE primary caretakers for threats to a child’s physical and emotional health and I respectfully call them Mama Bears. I do not know what a comparable Aussie term would be!  

A California mom with a 14-year-old child in heavy denial about soiling and no help from the men in her life.
January 13, 2012

Question:

How can we stop this madness, he literally poops in his pants, doesn't wipe, doesn't seem to care? He will go to school (8th grade) in shitty pants. When I ask him about his messy pants, he just lies and says it isn't him?? Help me please.

I am the parent of a 14-year-old boy who I have been told in the past suffers from Encopresis. However, while seeing this child psychologist at Kaiser in So. California for over a year, she never once suggested any remedies to help my son with this problem. We have since stopped seeing this Dr. I had hoped with age he would grow out of this problem, but this is not the case. He is 14 years old and in the 8th grade. He literally sits in his poopy pants day and night. When asked if he needs to use the bathroom, he simply just lies and says "no mom, I already did" then when asked if he wiped, he says "yes!!" but I am the one who does is laundry, most of which has to be thrown out. He leaves huge chunks of poop in his underwear, apparently he doesn't care that he goes to school smelling like constant shit. His smell is offensive to everyone around him.  It seems to "seep" out of his pores. Doctors in the past that I took him to while in elementary school always told me that he would eventually grow out of this as he matured....well he will be starting high school in this new year 2012 and it is only getting worse!! My husband (and Exxxx’s dad who does not live with us) both tell me and Exxxx that it is because he is "lazy" and that there is no other reason than that, period. So as you can guess this makes things here at home and at his dad’s house very difficult. 

When he finally does go to the bathroom, it is the size of a grapefruit, it cannot be flushed and must be dug out of toilet and thrown out in the outside garbage. We (I) have been dealing with this for years. He is my youngest of 4 children, and the only one with this issue. He has been neglected most of his life by his dad, only to be replaced by a "new wife and new child" he has failed the 6th grade and was retained. He has had emotional and social difficulties his whole life. I had hoped by this age that he would take an interest in girls and maybe start to step-up his hygiene, but this is not the case. He literally goes to school with his underwear filled with poop!! When I try to talk to him, he just stares at me, actually right through me as if I am not even in the room and appears to answer me with what he feels is the answer I "need to hear" so that I will leave his room and leave him alone. By the way, his room smells like an outhouse at all times, because he just sits in there in his waste.

As I'm sure you know, this is just a snap-shot of his problems, it would take me hours to tell his whole story, but I have just tried to "sum it up" for you in a nut-shell.  I don't know where to turn, when I used to take him to the psychologist he would just sit and lie to that Dr. as well.....I feel like everyone has failed this child, including me. Please help, I would appreciate any input that you might have. I am planning on purchasing the manual, but I must first wait till I have some child support $ to do so.  Thank you,

Dr. Collins’ Answer:

You both sound very beaten down and it is only a mama bear’s strength and resolve that has a chance of giving this child hope.  I’m sorry about those guys in your life. A good 95 percent of the parents on our SS forum are moms! Never have I gained so much respect for you mothers as I have dealt with this problem over the years. Most of the guys just seem to “scatter” or snipe from the sidelines. Some are really great and even go hands on and are very supportive, but...! 

Given his age and the duration of this problem none of his behaviors appear to be unusual. This is such an isolating, socially abhorrent state involving offensive smells, a disease carrying product, and the very private sexual area of the body that he is into heavy denial. No one wants to deal with it, much less your son himself! His staring right through you is something called an “altered state”, he has completely “turned off” in shutting you and anyone else out that attempts to deal with this problem. If you do order the manual it will be very difficult to get his attention and to recruit some hope and energy for change, but it really is about the only alternative left to you. Be sure to look up an inexpensive, even free copy of “Sneaky Poo” on the internet which helps to orient you and everyone else that this is not HIS or YOUR problem. The culprit here that you both have to face as allies is “Sneaky Poo” itself.

You say that you will be ordering the manual as you are able. Please do so. I think you will both find help in its pages because it is so very different from other approaches available and it may strike a chord of hope because of how definitive it is in assuring that just once a day for an hour it will assure no accidents for 90% of children within a couple of weeks. It is a bottom up approach with suppositories and enemas (S&E) which have the unique advantages of almost immediately giving very strong awareness urges of voiding urges and then reliable evacuation in a very timely matter providing immediate and successful feedback with much “relief.” Most kids are amazed and very happy, even as they may fight it in the beginning. However, it can take some days and weeks for them to catch on and swallow that this is best for them as everyone notices dramatic emotional and behavioral changes. Of course, getting him over the first step will be the most difficult as he is going to have to do the nuts and bolts of self-administration part with your reminders. Good luck

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A Colorado Mother mystified by a 4 ½-year-old child who has regular BMs on the toilet, but still has soiling before and after, except when going somewhere special when she is able to comply and not soil on request.
January 10, 2012

Question:

I will sum up the mother’s observations here as we had a lengthy exchange. The child has had soiling and occasional wetting incidents since she was 3-years-old and does not appear to be constipated or holding per the mother’s opinion and observations. She is compliant in sitting and having a daily BM on the toilet stool. The stools are “quite sizeable” and the pediatrician noted nothing remarkable from a standard X-ray. The catch is that she still soils before and after her daily bowel movements, but with special days by request she can control and avoid accidents. This is evidence per the mother of her having “control.” For me this is also evidence of  “holding” to get through that day. The household is described as “intact and solid.”  The mother requests, “So, I guess I’m trying to determine whether this isn’t just a soothing habit she’s created for herself or possibly something that could benefit from a solution such as yours. I’d hate to put her through this if this isn’t a method she could benefit from – would almost seem like child abuse to me.”

Dr. Collins’ Answer:

Frankly, this is an unusual case because of the lack of the usual indicators of bathroom avoidance, obvious postural holding behaviors, daily BMs, a normal X-ray, and compliance with holding requests for special days. Nevertheless, the incidents of soiling and wetting are characteristic of overflow incontinence and it is hard for me to avoid the conclusion that unconscious and habitual, incomplete evacuation (dysnergia) is occurring with her routine sits. One exam that might be done is a contrast X-ray to see if there are any unusual structural features of the colon. Usually a Barium enema is done for this purpose, but it is quite constipating and one leading authority, Marc Levitt, MD at Cinci Children’s Hospital, recommends the use of a soluble contrast medium instead. I can understand the mother’s reluctance to go to the “bottoms up” Soiling Solutions®, SS, protocol set forth in the Clean Kid Manual-V©, CKM-V, but I cannot think of any other home-based method to insure a more adequate and complete means of forming a complete evacuation habit. If biofeedback is available that would be another option. Two forms of biofeedback are mentioned in my November 22, 2011 Q&A response.  

My final initial response to this mother was, “Go with your intuition on what you think best. You are doing a good job on getting information.”  That still stands and I am sure that she will take action rather than wait too long as is often the case for many mothers who discover SS only when their children are 7-years-old and above.

A Licensed Professional Counselor in New Jersey finds herself with a 15-year-old boy with prior hospitalization for fecal impaction and was told that he would outgrow it.
January 6, 2012

Question:
I am working with this child and family. I am a Licensed Professional Counselor. The parents of this boy were told for several years by their pediatrician that the child will outgrow the problem. This boy is 15 and was hospitalized six months ago for fecal impaction. Afterward, the parents were directed to give Miralax daily. Was working for a time, but recently the boy has missed several days of school due to irregularity with bowel movements. Does your program work with adolescents? I am a Licensed Professional Counselor, working with a few adolescents who suffer from this problem.

Dr. Collins’ Answer:

Good for you on pursuing this matter! The past history you gave of reliance on Miralax and the promise that the continence fairy will alight some day with a magic wand for a cure demonstrates a lack of searching out more promising options such as I have described in my Q&A column for November 22. His hospitalization for fecal impaction is quite serious and should have spurred a more intensive search for treatment alternatives—something which you have done. At 15 years of age he is at some risk for permanent damage of his colon which could lead to a very intense week long program or surgical correction down the road if SS or biofeedback fails. The top of the line to go to for this issue when all else fails would be Marc Levitt, MD, a colorectal surgeon at Cincinnati Children's Hospital. He will avoid surgery if possible. His program is listed under my Encopresis Centers list under the Home menu tab at www.encopresis.com.

My Soiling Solutions® (SS) protocol is well indicated for this young man. He has a good chance of succeeding and becoming independent. The Clean Kid Manual© (CKM)  is in itself pretty persuasive and hopefully he can buy into the intense intervention that requires a daily treatment hour with brief timed sits and the stepped use of suppositories and enemas as required assuring an adequate and complete bowel movement associated with productive sits in the bathroom. A parent will have to enforce and oversee the treatment, but he should be able to do insertions of the suppositories and enemas with some degree of modesty. If he does not produce each day it will be very clear that he is subverting the treatment and the parent will have to become more engaged. If the parent and you can get satisfactory compliance you both will become heroes to him as he has been so crushed by a history of miserable failure. 

If you order the manual you will be registered on the SS Parents Forum and learn a lot as will the parent(s), if they also order a copy of the CKM. There are other teenagers on the forum so the support and insights that the parent(s) can receive from the other parents will be immeasurable. You will have a very high probability of becoming the go to person for encopresis in your area. Good luck.  

A full-time, working South Carolina mother with a 4-year-old daughter in preschool, wants to know if she can use the Soiling Solutions® protocol.
12/20/2011

Question:

We've been using Miralax for about 2 months now. My child, however, still appears startled when a bowel movement begins and many times needs me to carry her to the potty in order to "make it." My question: I work full time and my child goes to preschool. Can I use the Soiling Solutions method?

Dr. Collins’ Answer:

The beauty of Soiling Solutions®, SS, is that it can be completely carried out in the home. A complete bowel movement (BM) during its daily treatment hour is sufficient to keep her clean until the next day’s treatment hour. This also solves any problems with accidents which she may have had in preschool. The complete BM is assured by a special sequence of sits in the treatment hour with very short “free” sits and sits following suppositories and/or enemas as set forth in the Clean Kid Manual. This is a proprietary intervention which has been confirmed in actual practice. If a child is severely backed up she may require a “clean out” employing both oral and bottom meds before doing SS. If she has been going regularly by leakage, accidents, or with sits she may not need a clean out since the SS protocol may do that in its normal daily application.

The problem about how to fit this into your full day is a practical matter. This is where the mothers on the SS Parents’ Forum which comes with ordering the Clean Kid Manual can excel with their suggestions about alternatives you can consider. You will come to appreciate them deeply and may in turn be helping other mothers in the future. Some love to stay on the list to help the “newbies.” The manual anticipates most complications and helps you to understand and do what you have to do, but those mothers will help to assure and make it all work for you. There are now over 630 parents on the list.  Ninety-eight percent are all moms! You women can understand one another better that this guy can.

A very patient and loving, but exhausted, stepmother from Ontario, Canada with an overly indulgent bio-dad for their 7-year-old child.
December 16, 2011

Question:

My step-son is now 7-years-old. When his father and I got together he was 4, and at age 4 he was still going number 2 in his pants and also was requiring pull-ups at night. We kept him with us for the whole summer and started a rewards program for using the toilet to go poop. By the end of the 4 weeks he was with us he was using the toilet every time and stopped having accidents all together. This didn’t last long and he regressed back to his old ways shortly after. Whenever he came to see us we would give him rewards for using the washroom this helps, but doesn’t stop it all together. I do know that shortly after that first summer he had a piece of bowel escape his bottom a small loop came out. I can’t remember the terminology for this. Anyways, he now lives with us on a full term basis and is 7-years-old. He poops his pants every day. I have stayed very supportive and calm through all of these years of cleaning poopy pants but I am at my wits end now. He is constantly doing it, smells bad, and I have to clean his drawers every day. I am very frustrated, Rewards don’t seem to do the trick for more than a day or two, and he just goes right back. I have tried taking things away like the Xbox and that works for a short time. I just don’t know what to do, he does have an identified learning disability, but he is smart and does well at things when he applies himself but I am just exhausted 3 years of cleaning poopy underwear is just brutal, I am teaching him how to clean his own underwear I sit with him and run the water and show him how to clean it up I am hoping that once he sees how not fun it is and realizes that its now his job he will stop. He does have the ability to go, because when the rewards are coming in the plenty or Xbox is cut off he goes and doesn’t have accidents. So I wonder if he is too busy to take the time to go. I am just beside myself. I love him dearly but I am just his step-mom and have a 13-month-old whom I have to clean up after I shouldn’t have to do the same for a 7-year-old. My son is 8 and hasn’t had an accident since he was 2 years old, so I feel like the 7year old should be capable.... I seriously can’t take much more its quite stressing and his father doesn’t have to clean it up so he just says well he is still so little. But if it was my son he would lose it, my son picks his nose and my hubby feels that habit is grosser than crapping ones pants. I disagree. I could really use some information.

Dr. Collins’ Answer:

You appear to assume in your observations that your son could gain control over his bowels merely by insight and proper motivation. I disagree. There is a lot of information pertinent to treatment options and reasons for soiling in my answers of November 22 and December 13 of this column. This will help to give you more perspective. It will take a lot of effort, but at least you will have a workable and sensible strategy to choose from for your son. What I am picking up in your questions is a lack of support from your husband and the difficulty you would likely encounter if you were to take strong and authoritative action with your son in selecting a treatment program. This problem conflict can occur in any household, not just with a “blended” family. It can be very sabotaging for the child’s best interests.

The Soiling Solutions®, SS, option which I developed uses suppositories and enemas in a daily treatment hour. It assures regular and full bowel movements on the toilet stool day after day until an automatic association for bowel movements (BMs) when sitting on the toilet stool becomes well established. The soiling and control comes early in my program, even if continuing treatment is required. Your son will likely vociferously object to this approach and could play to your husband’s sympathies. Dad could become his heroic rescuer leaving you facing the same problem with even more hopelessness. However, when you succeed you will gain much credibility with your son. 

I strongly recommend that you and your husband read the “Sneaky Poo” book with your son which can be found on the Internet.  It should help everyone to understand that no one of you is to blame for this problem.The COMMON enemy for all three of you is “Sneaky Poo.” You all must cooperate in order to defeat it.  Good luck.

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What is (are) the original cause(s) for Encopresis?
December 13, 2011

Dr. Collins’ Answer:

This question is extensively addressed in my Clean Kid Manual© (CKM-V, fifth revision) which sets forth the Soiling Solutions® (SS) protocol in considerable detail. The CKM is supplemented by enrollment onto the SS Parents’ Forum with over 600 parents, It is very much dominated by mothers. The forum has proved to be a very important element for the success of SS. The mothers are an amazing source of support and practical advice for one another in overcoming their fear of using suppositories and enemas which is a central feature of SS.

But what does this have to do with the initial cause for Encopresis? Well the typical predominant medical account is that somehow, usually during toilet training, the child becomes anxious, fearful, stubborn, or oppositional about sitting and having a bowel movement (BM).  Other risk factors are autism and ADHD. This leads to a vicious cycle of holding where there is backing up of stool causing an enlarged, weakened colon. The withheld stool becomes dried out as moisture is absorbed from the colon into the surrounding tissues causing pain on elimination. The solution then is to encourage oral medications for softening and promoting gastrointestinal (GI) activity coupled with after meal sitting times/demands. The rational here is that more frequent, soft BMs will cause the child to be more accepting of sitting and emptying out his colon until the colon returns to normal size and strength.

Actually, I think that this is a reasonable approach in the beginning; however it all too frequently fails for about 40-50 percent of children after persisting for a whole year. In my view there are children who tend to be hardwired for stubborn, oppositional, confused, and very independent behaviors. They refuse to comply with toileting demands because it interferes with their ongoing activities as an original cause or they are afraid of a painful BM. The main factor may have been HOLDING ITSELF which becomes a well-established habit.  It is not well served by the oral, top down approach. The use of oral medications at the TOP of the entire GI tract has only partial, confusing, and much delayed effects on triggering voiding urges and an effective BM at the BOTTOM. The problem really is at the BOTTOM and it is best addressed by the rational use of a suppository or enema in a daily treatment hour which empties them for an entire day and makes accidents much less likely with lowered pressure and more normal consistency hot dog-like stools. Regular, more normal BMs are less painful and the bad holding habit gives way to a habit of normal release of stool that becomes strongly associated with the toilet stool. These bottom “rectal primers” create much more immediate strong and recognizable voiding urges and contractions that promote a competent and complete BM!

Basically, this is retraining. It allows a shrinkage and restoration of the colon to normal. The SS can be done entirely in the home by loving parents with the manual and the parents’ forum. 

By all means try the standard pediatric oral, “top down” approach, but be ready to go to SS as a highly effective in-home approach sooner rather than later.  NOT doing so will result in strengthening the holding response and causing more back up and colon damage. Everyone will be so much happier with this problem behind them.

A Michigan mother who is seeking reassurance as to a physical cause for her 12 year old son’s fecal incontinence.
December 9, 2011

Question:

My son has been soiling since he was a small child. He is now 12 and has not "grown out of it" as his pediatrician once told me. We have seen 3 GI doctors, he has had an MRI and we have done our share of "clean outs".....including enemas, laxatives and suppositories. This is a daily occurrence that has become a part of our lives and has disabled my son from participating in many activities. We would like to know if there are any other tests that maybe he hasn’t had that would rule out a physical complication. Thank you.

Dr. Collins’ Answer:

It is a typical scenario for parents to seek medical advice for children who do not have bowel control after several efforts to toilet train the child. The physician with his training will seek to rule out any organic bases for fecal incontinence when it persists beyond some reasonable length of time, currently age 4 years. A “rule out” can be based mainly on their having known the child and conducting a thorough history of the child. If their suspicion index is low they will assume that it is a “functional medical disorder” because further medical testing has a very low probability of coming up with anything new. The doctors then will instruct the parents to use orally administered top down stool softeners or laxatives to promote the easier passage of stool assuming that the child will learn by natural means to go on the toilet stool repeatedly and successfully until a toileting habit is established.

If this approach does not work the physician may advise charting and reinforcement for sitting and having bowel movements. A referral to a psychologist to secure better compliance with toileting efforts is also common. If this does not work they may refer to the specialty of Pediatric Gastroenterology. The PedGI might do more medical testing, but he is just as likely to reinforce doing more of the same. If these methods fail the physicians tend to fall back on such phrases and assurances that the child “will grow out of it” as this mother has experienced. They will resist further medical evaluation for an organic basis because again any positive findings are very unlikely and expensive. However, this creates conflict as many parents have considerable faith in modern medical science and are certain that there must be some further basic underlying organic issue. That is what this mother is seeking.

She has indeed succeeded in getting an EMG which is usually done to “rule out” a tethered cord which may interfere with adequate nerve connections for controlling the bladder or bowel.  This is an expensive test and it is fairly rarely done. A more common and relevant test is to use a high contrast medium (usually Barium) for an X-Ray so that a much clearer outline of the colon can be viewed to identify anything structurally unusual and compromising. Sometimes manometry involving the insertion of a balloon strip to assess contractions in the colon and the anal sphincters is done to see if there is normal activity. Other possibilities include a motility test to see how food is passed through the entire GI tract. Much of this can be looked up at www.iffgd.com which is the International Foundation of Functional Gastrointestinal Disorders and for which I wrote my article on Soiling Solutions® (SS). A copy of my article can be read at www.encopresis.com/Articles.html. 

The fact that this mother is still having to deal with a 12 year old child who continues to suffer from fecal incontinence is unfortunate and perhaps represents our society’s reluctance to deal seriously with such a disorder involving a very offensive, smelly body product and a very private, sexual area of our body.  I wrote about new techniques for treating encopresis in my November 22, 2011 Q & A response at www.encopresis.com. If these treatments (biofeedback and SS) fail then perhaps further more serious testing such as those that I mentioned above can be justified. 

An Illinois mother has a 10-year-old daughter facing across-the-board refusal to do anything that might help her to stop soiling in her underwear.
December 5, 2011

Question:

My daughter refuses to take the over the counter meds and refuses to use the toilet and soils her underwear. 

Dr. Collins’ Answer:

This mother’s question shows a typical picture of refusal by a child to comply with all attempts to treat a very private and embarrassing problem. She gives virtually no details as to age, family support, siblings, temperament of the child, etc. I will answer as best I can based on the all too typical picture of refusal and likely universal holding seen in these cases. Children can be very powerful in rejecting an intervention and escalate resistance to a degree which can cause parents to back off rather than confront the issue with more authority. This becomes more difficult with age which is another reason I believe that parents must default to more effective interventions earlier if they are available. However, currently health professionals are pretty much limited by training to just one approach which is the use of orally administered stool softeners or laxatives to make bowel movements easier and more likely during enforced sits in the bathroom. This can escalate into intense parent-child conflict because how do you get a child to take a pill when it clearly may require force and the child is in control of the act of swallowing.  Also, how do you get them to sit quietly on the toilet stool, relax, and coordinate the proper muscles and breathing to initiate a bowel movement which is quite normal for the vast majority of us? Tension and anger almost inevitably result because what is so obvious and natural cannot be communicated effectively to the child by verbal or logical explanations. 

Effective alternative treatments to this mother’s use of “top down” agents to soften stool have been recently discussed in this Q&A column, going back to 11/22/2011. Please read the Q&A column forward from that date. Once a parent gets some idea of the Soiling Solutions® protocol covered in the Clean Kid Manual she will have to overcome her fears about the use of biofeedback or suppositories and enemas. If she can do that, AND MANY CANNOT, she will likely find a path out of how “stuck” she has been and find a much happier and very changed child. These alternative treatments are much more immediate in promoting bowel movements in a more timely and consistent manner on the toilet stool. The child will experience more dramatic voiding urges and relief with more immediate bowel movements daily on the toilet stool. Frankly, modern parents and too many health professionals have no comprehension of the degree of learning and training which must be implemented.  This cannot be done by the traditional and dominant “top down” approach which may work for only 40 to 60 percent of children over the course of an entire year. Using pills at the top of the GI tract for issues that really exist far removed at the bottom end is really quite illogical and it can actually make things even worse. Doing this for too long can train more attempts to hold! How paradoxical is that! 

I am sorry that I cannot give this the mother the means for improving on the use of oral medications by continuing more of the same with variations in diet or behavioral means. She can continue to try, maybe with the help of encopresis forums on the internet and her daughter’s doctors. But, she should set a limit on how long she will attempt variations on the oral approach.  I recommend at most a one year trial. I am sure that with a 10-year-old she is well past that trial and has been more than patient.

Australian mother with a very young 3-year-old daughter wants to know if the Soiling Solutions’ Clean Kid Manual© (CKM) can be beneficial.
December 2, 2011

Question:

My daughter has been withholding her poos for 3 months now, resulting in frequent soiling. Is she too young for us to use you clean kid manual?

Dr. Collins’ Answer:

This mother did order the CKM. Encopresis is simply defined as fecal incontinence where a physician has ruled out organic causes for children over 4 years of age. It occurs in about 2 to 3 percent of the population and the most frequent onset occurs during toilet training, then preschool or school situations, or during periods of stress which can have many origins. Whatever the initial cause, it can quickly result in a vicious cycle where toileting demands and conflict inevitably result because of such a smelly and offensive body product. This mother identifies the central feature for the vast majority of cases of encopresis. That is a very bad and resistant to change holding habit. The vast majority of pediatricians and GI specialists today believe that Encopresis is due to an enlarged and weakened colon, but the holding is the initial basis for the enlarged colon! Hopefully this mother can get a good start to avoid physical damage to the colon which makes treatment so much more prolonged and difficult. 

The usual sequence for a bowel movement is to recognize voiding urges, initially hold, and then to relieve oneself. If diapers or pull ups are worn this becomes very easy and convenient as the child simply with minimal interruption in their activities simply feels the urge, squats, grunts, and lets the bowel movement naturally result. When this natural sequence of voiding signal recognition and then voiding happens over and over again an association forms for the voiding response to occur with the diapers on, but NOT when they are not being worn. As disposable diapers and laundering services have become so common and convenient we are likely seeing an increase in diaper “dependence.” This manifests itself very strongly when demands are made for the child to sit on the toilet stool over cold water and the resulting scary flushing sounds. Holding can result along with the drying out of stool retained in the colon causing painful bowel movements and reinforcing anxiety over having a bowel movement. The normal sequence is sabotaged and has to be retrained; it won’t, in many instances, magically reappear.

To counter this cycle most physicians today make a very simple biomechanical assumption that top down oral stool softeners will make voiding easier and less painful. This works in about 50 percent of cases in the course of a year of careful monitoring, lots of encouragement, and maybe adding in chart and reinforcing consequences for going on the toilet stool. However, for some situations and children it can result in more leakage and accidents because the stool is too soft and harder to control. Some children may hold more strongly to avoid accidents making the holding more engrained and resistant to change! The poor children (and parents—almost always the mother) find themselves trapped and unable to transition the child to a normal bowel movement on cue (the toilet stool). The children will have surprise accidents when sneezing, running, jumping, laughing, or thinking that they will simply pass gas!  They can go into denial, desensitize to smells or accidents, and reject reality in their little worlds.

The solution is now to retrain by biofeedback or use of the Clean Kid Manual© (CKM) described in my November 22, 2011 response for this column. Your child is too young for biofeedback so the more natural in-home process of assuring regular, successful, and relieving bowel movements on the toilet stool described in the CKM using suppositories and enemas during a daily treatment hour may be appropriate. The vast majority of physicians will prefer to have you avoid suppositories and enemas and counsel patience and sticking with the top down approach. However, they don’t have to live with the fecal incontinence and I have my own concerns about the resulting emotional and physical damage (enlarged and weakened colon and urinary tract infections) that could result. It is really your judgment call. If you can recruit your physician to stand by and monitor you that would be ideal if he is at all “open” to trying a new method. You will have to be very strong and parental in proceeding. You will have the support of other mothers (there are Australians) on the forum that you will be registered on with your purchase of the CKM. Good luck.

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A North Carolina dad with an 11-year-old daughter who is aware of voiding urges, but just cannot, or will not, go in the bathroom and hides her dirty clothing.
11/29/2011

Question:

My ex-wife, daughter, and I have been struggling with this issue (Encopresis) for at least 5 years. It started prior to our divorce 6 years ago, but has gotten NO better. We have been treating it with laxatives and the occasional suppository. Lately my daughter has begun to hide her dirty underpants and lying about using the bathroom...I am convinced there is an underlying psychological issue, but my ex is unwilling to explore that as a reason. I know my daughter knows she has to use the restroom...she just doesn’t...Any help will be appreciated.

Dr. Collins’ Answer:

This situation is so mystifying for parents and child that they find themselves casting about for all kinds of explanations, excuses, or blame games. Encopresis is an exceptionally difficult disorder which is really not understood by too many professionals, parents, and the public. It is really best to do a web search and look at “Sneaky Poo,” a free book on the internet which you can do a search for and download. It will allow all of you to step back and take a more rational problem-solving approach to this issue rather than get all tangled up in our various emotions which just get so negative when dealing with such an intractable and offensive issue involving a smelly and “dirty” body product.

There indeed is a real problem. Whatever its origin, there are so many possibilities. Some are very, very innocent and can occur for children with no significant family or training issues. So let us set aside the search for “original” causes. What we have now are “maintaining” causes! However started, we now have chronic and automatic holding, backing up of stool, increased abdominal pressures and an enlarged and weakened colon which cannot provide sufficient propulsive force for an adequate bowel movement. There has developed a maintaining vicious cycle of holding and not knowing how to coordinate muscles, posture, and breathing for improved and more complete bowel movements. These are old “bad” habits that have to be replaced by new or relearned skills. The problem that needs solving now is how do we initiate “new learning” to break the vicious cycle and initiate a virtuous cycle. That is not easy and it no longer can be done without a concerted effort by all three of you to address this issue via biofeedback or the Soiling Solutions® (SS) protocol addressed in the two preceding answers for this column (November 22 and 25).

I do address divorce in the Clean Kid Manual (CKM) which sets forth the SS protocol and in some really exceptional situations I have seen cooperation for this problem worked out. Even in intact households I have seen sabotage effectively scuttle retraining efforts if one or the other parent is not on board.  Children do not have their own long term best interests in mind and need good parenting! Your daughter will likely fight you and exploit any differences or weaknesses that you show as parents. I hope that your daughter has some insight and can respond to your coordinated parental efforts, but it will certainly take real parenting skills and great effort. It is very clear that by now little tweaks, magic diets, or words alone are going to break the evil spell of encopresis. Tell your 11 year old that now she has a real possibility for breaking this evil spell, but it will require her cooperation and commitment up front. All three of you will need to get together and work out a plan using the CKM. She needs to see your determination and concern for her future. She is an emerging young woman and she needs a good start now as she prepares for adulthood. Get it together and remember that “sneaky poo” is the common enemy that you all have to confront.

A California mom, with faith in her PedGI doctor, is becoming frustrated and seeking new approaches when Miralax and sits are not working for her 5-year-old daughter’s Encopresis.
November 25, 2011

Question:

Our daughter has been on and off Miralax, dealing with Encopresis for a couple of years now. We've recently been referred to a pediatric g.i. specialist and she's been undergoing treatment with him since April. There have been periods of improvement, when she's demonstrated control, but recently we've experienced a major setback and are just feeling quite frustrated. Our daughter has been very cooperative and deserves some improvement! We feel like we're just managing the accidents but not moving forward like we were hoping. I don't lack faith in our doctor, I am just trying to be as proactive as possible and be our daughter's advocate. How does your system work?

Dr. Collins’ Answer:

The on and off nature of your experience with your daughter’s control of soiling accidents has got to be a real emotional roller coaster ride. This is even more striking with your noting her cooperative nature. That is rarely the case with this disorder so good on the both of you! 

Your daughter’s age suggests that the traditional “top down” approach is not likely to work in the near future and that you may want to try another quite different approach. Both biofeedback options and my Soiling Solutions® (SS) protocol are the major effective alternatives these days. These are discussed in the prior, November 22, 2011 response for this Q&A column. 

Both biofeedback and SS work by retraining very habitual reflexes that have become scrambled causing a lack of coordination between the holding and the releasing/voiding responses. This is now being referred to as “dysnergia.” The usual sequence on recognizing voiding urges is to hold (clamping down on the External Anal Sphincter-EAS) to prevent elimination and then going to the bathroom and relaxing the EAS to allow an automatic voiding response to occur. A normal voiding response is typically fairly complete, but for these children they will have trouble initiating that response or even if it is initiated they will cut it off before completion resulting in more backing up of stool. Explaining all of this to your child is like trusting someone who has only read a book on piloting an airplane to fly the next airplane you board. The repeated experience of recognizing voiding urges and then successful and complete voiding while piloting the toilet stool is absolutely required. My Clean Kid Manual setting forth the SS protocol answers this and many more questions and issues which you can do in the privacy of your home with the help of the parents on the SS parents forum. However, if you cannot abide by the requirements of using suppositories and enemas in SS, then try biofeedback first. Doing nothing is not viable and may actually cause emotional and physical harm if you delay too long in hopes of the “continence fairy” coming to rescue your child. Good luck.

California mother’s plea for help with a 6-year-old daughter, who has a history of both Encopresis and bedwetting with no end in sight.
November 22, 2011

Question:

My daughter has always had constipation throughout her whole life. Now it has gotten to the point where she poops a little bit in her pants numerous times a day. She also wets her bed almost every night. I'm so frustrated and don’t know what to do anymore. PLEASE HELP ME AND HER!

Dr. Collins’ Answer:

I am sure that the both of you are very, very frustrated and unhappy over “sneaky poo and pee.” There is a free version of the "Sneaky Poo" book online, check it out. The book helps to reorient you into recognizing that the enemy is not one or the other of you, but “sneaky poo” itself! That helps in taking constructive action which I highly recommend that you do as soon as possible.

There are good potential solutions for you that will help to break your impasse with this problem. At 6 years of age and a likely, by now, enlarged and weakened colon pressing on her bladder you should not delay implementing a new treatment approach.  There are two basic retraining methods that could help you and your daughter to have a fresh start. 

One is EMG (ElectroMyoGraphic recorded) or manometric (pressure recorded) biofeedback to help your daughter better tune into her voiding sensations and more effectively coordinate her muscles for successful bowel movements. EMG uses surface monitor sensors to detect and display muscle tension for selected muscles in the pelvic region so that your daughter can begin to learn the right muscle coordination that will help her to consciously hold and release her bowel and bladder more successfully. She will see this on a monitor and “feel” what is going on inside her body as she learns to control her relevant muscles. This is increasingly being done by physical therapists in an office setting. Manometric biofeedback does pressure recording via balloons inserted into the rectum and anal passageway. This allows the child to recognize and “tune up” her awareness of pressure in the rectal area and also to train her “poop motor” to be more effective in releasing stool when she expels the balloon on request.  This latter form of biofeedback has to be done in a medical clinic setting. Perhaps there is a University medical center available to you that uses this method.

The other major alternative is my Soiling Solutions® (SS) protocol which can be done in the home by you two with the help of the Clean Kid Manual© (CKM) and a parents’ forum using “rectal primers” (suppositories and enemas) to train awareness and elimination while on the toilet stool day after day during a daily “treatment hour.” Repeated success with brief sits on the toilet stool leading to relief will replace her bad holding habits with a more coordinated and reinforcing relief habit so that she takes over this process on her own. The soiling stops quite quickly for most children. 

If the bedwetting does not resolve with treating the encopresis, then the CKM has two new chapters on day and night bladder control. Get going mother and daughter, do not put up with “sneaky poo (or pee)” any longer.

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A Western Australian mother with a 6-year-old boy who is not responding to a weekly suppository or diet approaches for a clear case of holding behavior.
11/18/2011

Question:

My almost 6-year-old has had a constipation problem since around 12 to 18 months and it became evident around 3 years ago that he was 'holding on' so he didn't go. I remember initially, when I first saw our GP, that he would run around in circles absolutely screaming and when he did do his poo his straining looked like he was giving birth. We started seeing a pediatrician who did an X-ray and even though he had 5 BMs the day before, his bowels were full. He put him in hospital for the day for 'extensive' treatment which consisted of a single enema resulting in 1 BM. The treatment ever since (after seeing a 2nd pediatrician) has been laxatives (parachoc, lactulose, laxettes). The pediatrician did several tests including a rectal biopsy and confirmed it was just him being stubborn after possibly suffering a tear when he was young. He has been on laxatives on and off and when he is on track I reduce the laxatives and eventually he goes backwards. We have tried a hypnotherapist (had a little success but went backwards again). Went to see a counselor for him and she blamed us. Rewards etc. only work for a little while. It affects his moods, appetite, our family life etc. His answer to why is: it's going to hurt, I don't like doing it, it takes too long, life is too hard. I have today purchased your manual so am waiting to receive it. He generally goes once per week but mainly that is due to us giving him a suppository. While I am waiting to receive your manual, based on his history, do you think your program is likely to help?

Dr. Collins’ Answer:

What a dramatic example of very obvious holding behavior! The causation here appears to be quite clear, painful bowel movements. Poor kid (and mum)! His straining to push while at the same time he is holding is called dysnergia. Parents often do not understand that this is happening because it is not obvious. The weekly suppository is just a clean out, not a systematic form of “conditioning” successful bowel movements each day during the Soiling Solutions®, SS, “power hour” when doing short sits on the toilet stool. That is the missing ingredient in your program up to your receiving the Clean Kid Manual© that you have ordered. The more frequent bowel movements will result in more normal, soft, and “fresher” sausage-like stools (hot dogs over here) with normal non-painful and good relief sensations. Repeated success and the experience of natural relief from the built up pressure will help train him to release and relax his anal sphincter when he sits on the toilet stool. Right now it is a cue for holding. He will “desensitize” to any anxiety over having bowel movements. The Clean Kid Manual© (CKM) will lead you through the process with the help of other mothers on the SS parent’s forum. There are a number of Australians on the forum. They are veterans at having been through pretty much the same set of issues, sometimes in opposition to their physicians. I wish it were not so, but I have written elsewhere about the source for this bias against the use of suppositories and enemas. 

Share this website with your physician and try to get his agreement and assistance to monitor you. Do not allow him to change the actual protocol. They think of suppositories and enemas only in the context of emergency rooms or periodic clean outs in severe situations. They do not think of their more routine use for training or retraining purposes to have successful bowel movements once a day on the toilet stool. They are perfect for training because of their immediate actions in creating awareness cues to void and then powerful contractions to empty in a very timely fashion. Oral medications just take too long to initiate urges since they have to go through the stomach and several feet of GI Tract. The SS method is designed to have your child develop his own awareness, start up his “poop motor” more quickly, and take over from the artificial primers. Physicians are not well-versed in learning theory and mostly think in pure bio-mechanical terms. That is often very appropriate, but not here.

Iowa mother with an 11-year-old daughter who is completely in denial over having Encopresis after several years of being accident free.
November 15, 2011

Question:

My daughter was diagnosed at the age of 4 with ADHD, ODD and mood disorder not otherwise specified. At the age of 5 she was having accidents took her to a specialist who stated it was all mental health issues and that it was behavior. She was put on Miralax. We had not seen anything until two weeks ago a discovered when doing laundry that there was a horrible smell. She had been soiling in her underwear and hiding the underwear and not doing any hygiene on herself. At the same time she had been complaining of stomach pain. I thought it could be due to premenstrual issues. Therefore I took her to the doctor and he had her do a urine test. To my surprise I went in with her and she refused to sit in the toilet ... therefore, I gained suspicion. I started to clean her and she had poop all over her inside buttocks it smelled so bad. I am not kidding it took me almost 2 hours to get all the poop out. When questioned, she says she does not feel she needed to poop and she was uncertain on when she had pooped. Could she have Encopresis? The doctor again said to just give her Miralax, I just don’t see how she could not smell when she poops or even clean after herself. Please help me I am so confused.

Dr. Collins’ Answer:

The sudden reappearance of Encopresis after a much earlier remission is called secondary Encopresis. The child’s reactions here are very typical with denial and hiding of the evidence. Encopresis is a medical functional disorder which only requires soiling in inappropriate places (clothing) after age 4 years with no identifiable physical cause. In this case the mother describes horrible smells, dried out, and caked fecal residue in her child’s buttocks. This is evidence of severe holding behavior which is really not under her control. You have here a confusion of voiding cues, conflicting holding and voiding responses that have become automatic and which are not subject to voluntary control. The medical terms are many for this feature, but the most common is dysnergia. She now reacts to the threat or emergence of stool (“sneaky poo”) with auto holding, much like we might do if someone threatens our eyes with a finger or even just eye drops. It goes even “deeper” now because sitting on the toilet stool only causes confusion as she cannot release there, but can only do so in the comfort of her clothing even as she wants to hold it back. Her accidents are truly accidents because of all of the pressure of backed up accumulated stool will result in oozing, leakage, chunks with bending, running, sneezing, laughing, etc., etc.!

The earlier solution of using Miralax worked because her stool was softened and she had not developed a severe holding/release conflict habit (dysnergia). Miralax combined with behavioral reinforcement is often successful for younger children with a 50% success rate after one year. That, frankly, is not very impressive and it is why alternatives have been developed like biofeedback or my Soiling Solutions®, SS, protocol when the problem persists, often for months or years.  Biofeedback has to be conducted by trained personnel in a clinic setting which could be checked out at a major University hospital. Soiling Solutions® can be done in the home with the assist of the Clean Kid Manual (CKM) ordered from the store on this website. That purchase also gives the parent or health provider access to the SS Parent’s Forum which includes physicians, nurses, psychologists, dieticians, and other parents all using the CKM. Just keeping your child cleaned out is an inadequate strategy. Both biofeedback and SS are training procedures to assure normal holding and then release on the toilet stool. I believe SS to be superior because it can all be done in the home and it assures repeated voiding success on a toilet stool in the home using “rectal primers.” Techniques are described on how to generalize voiding success to the school or other bathrooms outside of the comfort and security of the home.

A Canadian mother without good access to pediatric care has an almost three-year old- daughter holding for four plus days, even with oral stool softeners and laxatives.
November 11, 2011

Question:

Around time of birth of sibling (almost 6 months ago), our daughter began withholding stool. As we had friends whose child went through a similar problem for some years, we met with our family doctor and asked to be referred to a pediatrician who comes from out of town (we live in a remote community). We met twice with the pediatrician and were advised to use the max dose of Lax a day. This worked for the first 5 months. However, over the last two weeks the problem has worsened. Even with Ex-Lax and Lax-A-Day, our daughter can withhold stool for 4 + days. Our local clinic doctors don't seem to have much experience with this or advice to offer and the pediatric doc is no longer visiting until spring. I know I can't give ex-lax for much longer. What dose of Lax a Day (currently 17 gram per day) and other laxatives can we use to help clear out her bowel.

Dr. Collins’ Answer:

A key approach for this mother was to use local clinic physicians to gain the services of a visiting pediatrician for her child who has all the features of encopresis marked by “holding” her stool. Encopresis is not diagnosable until 4 years of age by somewhat arbitrary diagnostic rules. However, the obvious holding here clearly indicates that she is well on her way toward encopresis, which will impact her physical (enlarged colon) and emotional health. The pediatrician’s prescription for stool softeners and laxatives was a perfectly appropriate and standard initial procedure. The fact that this worked for five months was great and promising, but the reversion to holding indicates that something different has to be initiated. 

The mother requests instructions for a “clean out” using top down purgatives. She should also request advice on “bottom up” medications, that is, enemas and suppositories to more completely assist her child in elimination and possible obstruction.  These are covered in the Soiling Solutions® (SS) Clean Kid Manual-V (CKM-V) as part of a more comprehensive treatment protocol. They are a perfectly acceptable medical alternative for clean outs

I encourage this mother to order the CKM-V for use and supervision by her available clinic physicians.The clinic would be well-advised to have a copy on hand. The physicians should not alter the instructions set forth in the daily treatment hour, but can otherwise assist her in medications and procedures. The mother must do the application of the suppositories and enemas herself and can get much instruction from the manual, youtube.com videos, and the parents on the SS Parents’ Forum which comes with ordering the manual. The clinic personnel can also be on the parent’s forum which includes pediatricians, other physicians, nurses, and other health professionals if they order a CKM-V. The clinic may call me or Dr. Birnbaum of the Mt. Kisco Medical Group in New York if they have issues of legitimacy. Dr. Birnbaum’s foreword to my CKM-V can be found at www.encopresis.com under the “Clean Kid Manual” menu tab.  Also, my medical journal article can be read at www.encopresis.com/Articles.html. Your reaching out for help to do something definitive this early is admirable. Good for you.

A Kentucky mother has an almost 4-year-old boy with “sticky” bowel movements and “somewhat low muscle tone.”
November 8, 2011

Question:

My son has had chronic constipation and been on Miralax since 10 months. He is pee trained but refuses to poop on the toilet and has several sticky small bowel movements throughout the day. I am losing hope that he will outgrow it by age 4 and wondering if you have any advice ... could this program help? He does suffer from somewhat low muscle tone but I don't think that's the issue.

Dr. Collins’ Answer:

I follow other Encopresis forums on occasion to view what is going on with respect to parent and physician’s approaches. This question brought out some observations that come up occasionally and I will address each in turn.

Sticky bowel movements are basically a result of the most frequently prescribed stool softener in the USA, Miralax. The consistency generally will vary from applesauce quality to peanut butter. This means anything but normal hot dog like stools which can be more easily detected by the ano-rectal sampling mechanism. This over-reliance on Miralax has always amazed me since in a number of children it actually promotes bowel accidents and even stronger efforts by the child to “hold” even more desperately to avoid the toilet stool. Physicians must learn to move on to alternatives if holding and toilet refusal persists for six months to a year. This could be all too true for up to 50 percent of children who could suffer from an enlarged, weakened colon causing even more emotional and physical damage. The children could, in fact, be being trained for even more holding and causing more damage! In medicine this is called “iatrogenic” or physician-induced illness. Your child is young and you have the opportunity to avoid this outcome.

The issue of “low muscle tone” is an actual syndrome of “floppy” muscles with poor control and coordination. It could be relevant since muscles are involved in both the holding and the voiding reflexes, but this should not be a cause for resignation and acceptance of an intolerable problem. This parent, and any other, should apply the most effective treatments available to them after, at most, a one-year trial of Miralax recommended by most pediatricians and PedGIs of today. The alternatives now include Soiling Solutions® (SS) which can be done in the home following the instructions in the Clean Kid Manual and an associated parents’ forum or biofeedback in a clinic setting. If both of these more directed and focused conditioning programs fail then the services of a colorectal surgeon should be sought. The colorectal surgeon could assess for appropriate surgery and/or a maintenance program involving both enemas and laxatives.

Medicine is still an empirical science that requires evidence and outcome data to assess what is most likely to succeed in treatment with the fewest side-effects. Parents have a special role to play in assuring that the best available approaches are tried after reasonable trials. Assurances that the continence fairy will show up someday if you persist in the standard “top down” stool softener treatment for over a year is to be rejected. You are doing the best you can under the circumstances. Keep on trying.

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A California mother with a 7-year-old daughter wonders about hypnosis as a possible treatment for Encopresis.
November 4, 2011

Question:

My daughter suffers from Encopresis ... do you think hypnotherapy can help? If yes, can you recommend somebody?

Dr. Collins’ Answer:

Hypnosis is a legitimate medical procedure and it has been found to be successful for Irritable Bowel Syndrome (IBS) for adults.  To my knowledge it has not been studied for treating Encopresis. Frankly, there are many parents who cannot conduct the Soiling Solutions® (SS) program because of their fears over using suppositories and enemas. I really would rather parents try treatment alternatives until they feel that there are no options left. But, they should not chase alternative treatments or delay biofeedback or the SS program for too long. The problem is that permanent damage can result from an inadequately treated enlarged colon if it persists for too long. 

Hypnosis is really not all that mysterious a process and actually is common in our everyday lives. Attending a movie and becoming very engaged in it is actually a common example—you leave your ordinary life experience and start living another in the context of the movie.  Sometimes it is called the “magic of the silver screen.” The flashed images on a flat screen become more and more real and you have emotional reactions to the events portrayed there. Children have a lot of fluidity and capacity in mixing fantasy with reality and that can be used to engage their cooperation. 

A psychologist or clinical social worker with additional certification in hypnosis could be helpful here in reviewing your child’s circumstances, your inputs, and coming up with suggestions in a hypnotic state that could be helpful and persist after sessions.  Often Encopresis is just a cycle that has to be broken and suggestions about awareness of voiding urges and responding to them sitting on the toilet stool could be useful. Certainly an evaluation session and some more sessions may eventually lead to success in the child’s ability to reduce conflict, fear, or other inhibiting emotions to become successful.

Although I did practice hypnotherapy some years ago it has to be so custom-fitted to individual circumstances and the child that it is not easily transmittable for general application to children with Encopresis. The advantages of the Soiling Solutions® (SS) approach with the Clean Kid Manual is that it is more generally applicable and has very specific training steps to turn successful voiding on the toilet stool over to the child by the parents within their own home. Also, since SS can be reduced to a manual it is really cheaper. It gives the parents responsibility and credit for what they do in the child’s eyes and creates a stronger child-parent bond. 

I cannot give this parent a specific referral. Most state associations for psychology or social work have a referral service.  Psychologists have a national directory at www.nationalregister.org. The referral source should be able to list or direct your request for hypnosis. Good luck.

California mother with a 10-year-old son who has developed a continuous cycle of holding with no end in sight.
November 1, 2011

Question:

My son has had Encopresis since he was about six, following a particularly bad bout of constipation. About one year into the problem, we started to see a PedGI at UCSF. We were told to "clean him out" with a laxative, then use Miralax. Things definitely improved, and our problems seem small compared to some on your site. However, the problem persists. He passes a bowel movement once every three to four days. In between, he usually has a small mess in his underwear, maybe a tablespoon at the most. About three months ago, I removed the Miralax from our routine and kept in the fiber supplement that had also been recommended. The staining greatly improved. But then he complained some of his bowel movements were painful again. I put the tiniest amount of Miralax back into the mix, and things have gotten worse. He is not "strong-willed," and he is cooperative about sitting on the toilet (after breakfast and after dinner, as per PedGI instructions) and writing down whether or not he's gone to the bathroom each day. He doesn't like to talk about the disorder, but he is agreeable about "solutions" (that don't seem to have worked!) I've never broached the subject of an enema with him. I guess I want to know what we can do? I'm not sure that he needs to be "cleaned out." I believe that if he weren't constipated, his underwear would be clean. Yet I don't want to give him more fiber if it makes his BMs hurt. Thanks in advance for any advice and also for this website. It's reassuring to know that others struggle with this issue for years. I definitely got the sense that the PedGI felt we should be done with this by now. I haven't taken him back in a year or more.

Dr. Collins’ Answer:

This mother, like the last Q & A in this column, has been very compliant with the predominant “top down” approach of using stool softeners and fiber for her son’s Encopresis. She has never used a “bottom up” approach of suppositories and enemas such as that required in my Soiling Solutions® (SS) protocol. The common “top down” approach indeed can work and does for 50 percent of children in one year, but we are talking four years here! There is a natural reluctance to go to suppositories and enemas which is common for most medical professionals and the culture at large. This is quite understandable, but this mother and child have approached a critical choice point - continue as is, or go to SS, which is carried out in the home with the instructions and explanations contained in the Clean Kid Manual (CKM) using a daily treatment hour using highly effective and immediate pooping agents (rectal primers) or continue with years ahead of depression and an abnormal life. A major treatment center has reported an 80% success rate after 8 years of “top down.” I find that unacceptable. Soiling Solutions® is a retraining program which assures day after day effective and complete bowel movements quickly on the toilet stool with attendant reinforcing natural relief. The program naturally begins to “tune” the child’s success to a point where he takes over and no longer requires the suppositories or enemas. 

Now what if there has been so much physical damage to the colon because it has been weakened and enlarged for years that it does not recover? That does happen and this is why I think pediatricians are delaying adequate treatment for way too long.  Most PedGIs state that it may take 12-18 months for the colon to have sufficient recovery that it can efficiently push stool on down with adequate force for complete elimination. I have had children go longer; and they may be more subject to occasional relapses. Very rarely, there may be a child who requires dependence on the suppositories and enemas for the rest of their lives.  However, even here there are options where larger volume bag enemas and the occasional use of Ex-Lax can eventually make a difference when done with the SS treatment. Also, a colorectal surgeon could be sought out for evaluation and treatment as yet another option. There is no guarantee here, but you have to do the best that you can for your child. With the purchase of the CKM you have access to other parents on the SS Parents' Forum who are very insightful and supportive. 

I have dealt with this issue for years and any individual outcome is difficult to predict, but soiling is quickly halted in 90 percent of children within two weeks while the SS protocol itself may have to be carried on for longer. Most parents appreciate this and never want to go back to what was. 

Wisconsin mom has a 7-year-old boy who is a huge soft poop producer three times a day with weekly clean outs!
October 28, 2011

Question:

My son has always had a large volume of stool ever since he was a baby. At age 4 he was potty trained but within weeks began a pattern of withholding. His pediatrician recommended Miralax which we did until age 6 with some success. At age 6 he started having frequent accidents. He had hard stool coming out a little at a time. We saw a therapist because we believed it to be behavioral. Finally we saw a gastro physician & received the diagnosis of Encopresis. For the past year we have been doing weekend cleanouts, nightly variations of either Miralax, Ex-Lax, mineral oil, MOM or a combo. He sits three times daily after every meal & still has daily accidents. He stools large soft amounts at each sitting. He has small or large soft accidents one to three times a day. His doctor says to continue cleanouts, but I feel like all he does is stool. I am often surprised by the volume of stool he has each day. I feel like we are missing an important piece of the puzzle. Is there something we are missing? Should he be going that frequently? We are emotionally drained & isolated.

Dr. Collins’ Answer:

It would appear that this child’s medical supervision with the sustained use of stool softening and laxative agents has been very effective in preventing a lot of fear and anxiety surrounding his bowel movements. The mother is to be complimented for her excellent compliance. What is very interesting to me is that the standard pediatric “top down” approach here has been given the best possible chance to succeed, yet the soiling continues and you have very large bowel movements throughout the day with reasonable compliance by the child for sitting. So what is wrong?

A striking feature here is the overproduction of stool. Sometimes we encounter the use of too much fiber and stool softeners which actually cause this overproduction because they enhance bulking action and the mixing of air with the foodstuff. Two problems result from this. One is maintaining an enlarged and weakened colon with incomplete elimination due to an overconditioned holding habit (a more complicated medical term is “dysnergia”). Second, the overly large stools still produce a lot of internal pressure and any movement, exercise, sneeze, etc. can result in “accidents.” This second problem then can cause the child to practice and strengthen his holding habit so as to fruitlessly try and avoid further such accidents.  How paradoxical!  The accidents themselves produce more accidents in a kind of vicious cycle. Usually I am dealing with a bowel movement-pain vicious cycle!

The problem here is that the overuse of softeners, laxatives, and fiber (not mentioned?) along with the holding habit is really not being addressed by the “top down” oral agent approach. The problem of holding comes from the bottom of the GI tract and it is that brain/bottom connection that is better addressed by biofeedback in a clinic setting or my Soiling Solutions® (SS) protocol in the home. My Clean Kid Manual (CKM) and the SS Parents Forum makes this approach much more informed and effective in gaining compliance using suppositories and enemas in a daily treatment hour with more striking and complete elimination over time. In SS the overuse of oral stool softeners and such is weaned down until a more normal and virtuous cycle is established.

CAUTION:  the pediatrician may be open or very “closed” to your trying out SS. Have him read the foreword by a PedGI to my new CKM-5 (fifth revision) at www.encopresis.com under the Clean Kid Manual Tab. Dr. Birnbaum (or I) would be glad to talk with him. 

You have been a very good and compliant mom, but it is time to move on and try something different.

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Ohio mother of a seven-year-old daughter with constant soiling and conflict ... missing out on normal lives and a loving relationship.
October 25, 2011

Question:

Please help me! My seven-year-old daughter is now wearing a diaper and is having a bm several times a day. We have been dealing with this for over two years and have gotten three doctors opinions. They put her on Miralax, then recently probiotics. Now she is not telling me and actually siting in her stool for a couple hours. She fights with me to go and says she doesn't care that she had accidents. I have kept her home from school ten times this year and it its only October. I'm getting angry at this point because she isn't trying to help herself. As I write this she is sneaking into her room and I know she is pooping but if I confront her she says no she doesn't have to go. I have made it her problem by making her clean it but she doesn't seen to care. I find myself crying over this daily and I an becoming mean to her. I don't want her to be made fun of and she had no life at this point. I can't take her to the store because I'm afraid of an accident. Tomorrow I will keep her home again and I'm ready to throw in the towel. Nobody has answers and I had her doctor paged today and he said to not give her Miralax and see him Tuesday. That's fine but I can't send her to a baby sitter because I can't expect them to change get diaper, and so now I miss work and she misses school. Please help me. I'm so close to losing it!

Dr. Collins’ Answer:

The fact that your daughter’s three doctors are all stuck and prescribing variations on the “top down” method using stool softeners, laxatives, or, more recently, probiotics with no beneficial results is surprisingly common. The fact that the top PedGI researchers in the world report only a 50 percent remission rate after a year for their “top down” approach demonstrates a real issue in understanding one of the major bases for this problem. That problem, simply put, is HOLDING, an unconscious reflexive habit often coupled with anxiety that the child cannot verbalize or resist in any conscious, intentional way. Move a finger toward your eye, what happens? You will protect your eye by shutting your eye (not unlike the anal sphincter), yet you can open or shut it at will at other times! The child is clamping up with the sensations of any poop trying to exit. You have to learn to tolerate keeping your eyes open for eye drops or contact lenses. Same here for suppository/enema entry or poop exit!

Go to www.encopresis.com (this website) and look under the Clean Kid Manual (CKM) menu tab and check the CKM out.  One sub-menu tab will link you to recent forewords by a PedGI and a Social Worker mother who explains the holding issue very simply and well. The PedGIs are beginning to understand that holding is a major issue and use terms like dysnergia or dyscoordination which only, in my mind, overcomplicates a very simple issue. The real issue is that the voiding-brain linkage is compromised at the bottom of the GI tract and that an effective intervention is to be found there. This is recognized by the application of biofeedback done in a clinic setting or by Soiling Solutions® (SS) done in the home with the aid of the CKM and the special SS Parents Forum that comes with ordering the CKM. Presently there is a lot of cultural and medical resistance to the use of suppositories and enemas, except maybe in emergency rooms or for major occasional clean-outs. 

The SS approach both addresses the over-conditioned holding habit and any fear that may be associated with bowel movements with a daily treatment hour designed to halt soiling very effectively while moving the child toward bowel independence. It is basically a re-training procedure. The manual addresses all issues and the associated SS Parents Forum provides incredible support and innovative advice—which provides me with great feedback and hence the reason why the Fifth revision of the CKM has just become available. 

The mother of a five-year-old Illinois boy, with daily fecal soiling, is told by his pediatrician that he does not have Encopresis, OH!  REALLY?
October 21, 2011

Question:

My son was very late to potty train due to his strong resistance against it. He finally mastered urinating right before his 5th birthday. While he has pooped on the potty a handful of times, the rest of the time he poops in his pants. It comes out in small amounts several times a day. Until now he did not have accidents at school, but now has soiled himself twice the last two days. He also has extreme anxiety at school and is getting treatment for selective mutism (a social anxiety disorder). My pediatrician just keeps saying, it is behavioral and that there is nothing I can do except wait. It is taking over our life - our house smells of poop - small pieces of poop have come out of his underwear at times, we don't like venturing too far from the house in case he has accident. When I ask my pediatrician if it is Encopresis, he says NO! I have tried rewards, incentives, etc. Any advice?

Dr. Collins’ Answer:

How depressing! Your pediatrician has to look up and read his diagnostic manual on Encopresis! Fecal incontinence without an organic cause at age four and beyond is indeed Encopresis. Then he adds merely waiting until what? The continence fairy? Just what kind of treatment is that? This is unforgiveable given your efforts and the situation affecting you, him, and the whole household. There is urgency to solve this problem with an anxiety disorder present and at this critical period in your son’s life.  There are both negative physical and emotional consequences for allowing this disorder to continue.

My Soiling Solutions®, SS, is his best available home-based care option for him at this time. However, if you are unalterably opposed to the use of suppositories and enemas perhaps you will have to wait for the continence fairy while doing what PedGIs call, “maintenance therapy,” which is what you have been doing. Soiling Solutions® can be implemented through the Clean Kid Manual (CKM) which presents a detailed plan and options. The parents on the SS parents’ forum would also be available to you as well with its purchase.  Run this all past your son’s pediatrician. I will be happy to talk with him if he initiates the call to me. If he prefers to talk to a fellow MD he may contact Dr. Audrey Birnbaum, a PedGI at the Mt. Kisco medical group in Mt. Kisco, NY. Dr. Birnbaum has a foreword in my recent CKM-V. Go to the Clean Kid Manual menu tab on this website to read it. Maybe we can get him on board and he may be very appreciative. 

I am so sorry that I cannot be more positive and sugar coat this problem. The only remaining alternatives that I see would be biofeedback conducted in a clinic setting or seeing a colorectal surgeon or PedGI. Frankly, most PedGIs would just continue what your pediatrician has been doing.

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New York mother wondering about an enlarged colon and how much poop a small 4-year-old daughter’s body can contain.
October 18, 2011

Question:

My 4-year-old daughter has been holding since just before her 2nd birthday. I've been reading about Encopresis, and learned that the colon can become distended. What exactly does that mean? How much poop could be inside such a small body?

Dr. Collins’ Answer:

Ah, yes, HOLDING back on pooping urges from a very early age can lead to an enlarged, stretched out, and weakened colon which cannot propel the stool forward as well as it should. The colon is a large storage sack, but even it cannot hold all of what we eat if we continually block the anal exit by reflexive habit and fear of a bowel movement. Once this habit of holding becomes well established it interferes with having normal daily bowel movements and a backup of stool becomes unavoidable with unfortunate consequences. The stool will tend to “dry out” as the surrounding tissues absorb the fluid contents from the colon creating hardened stool and more difficult and painful passage which only causes the child to HOLD even more desperately compounding the problem! You may see small chunks of stool escaping and some escaping fluids that may come from getting around a blockage. This is why the most common prescription for this problem is the use of stool softeners (Miralax, lactulose, emulsified mineral oil, etc.) which assumes that the bowel movements will become less painful and scary. Many pediatricians appear to assume that this will lead to an automatic solution over some period of time. However, too many children do not make that transition and continue to hold causing a continuation of backup and even more accidents as the softened stool is more likely to leak or escape with activity, sneezes, etc. Usually the parent can observe the holding behaviors and demand sits that accomplish even more holding now on the toilet stool. The toilet stool and the bathroom itself paradoxically then becomes a cue for holding!  Gr-r-r-r, how defeating this can be for everyone! Anger, distress, upset parents, and negative social reactions; all inhibit and sabotage the ability to relax the anal sphincter and allow normal evacuation.

A kind of “brain lock” and a repeated parent-child conflict loop results producing an impasse and no progress. One solution here is a “clean out” of the backed up stool with strong, “top down” oral laxatives. Parents and physicians tend to resist the use of the more highly effective clean out “bottom up” agents like suppositories and enemas. They are used in emergency rooms for severe backups!  How much gets backed up - well my parents with children your age have reported variously “… three beer cans came out!” or 5-10 cups of stool! Autopsies (colons can rupture—very rare) have revealed up to half of a child’s body weight in accumulated stool. Actually, then leakage and accidents can be taken as a good sign! Yech!

Clean outs are just temporary solutions and backups are just going to reoccur because no real evacuation and relaxation training has been applied! Also, some enlarged and weakened colons may not recover well and remain permanently stretched and require daily suppositories and enemas for an extended time or life. The Soiling Solutions® (SS) protocol with the Clean Kid Manual and the associated SS parent’s forum is the best hope for recovery if the standard medical treatment approaches fail.  Biofeedback is another possibility. The remaining alternative is surgery as assessed and performed by a colorectal surgeon.

Michigan 33-month-old boy who poops while standing up and resists the toilet stool ... but not for urine.
October 7, 2011

Question: 

My son is close to turning 3-years-old and we have been working on potty training. Urinating in the toilet has been a breeze, he rarely has accidents and is staying dry consistently through the day. The problem is poop. He is completely resistant to pooping on the toilet. He has never been the kid to squat in the corner or disappear when pooping, he poops standing up and moves on. I am wondering how to get him to poop on the toilet, without keeping him from peeing on the toilet. I am wanting to go back to diapers, it is easier on both myself, my husband and our daycare provider. I am out of options it seems like because the urinating process is down, but the pooping problem is far from over. Thanks for your help.

Dr. Collins Answer:

It is so frustrating for all when it is quite clear that the child is urine competent for the bathroom and the toilet stool, but not for poo. This actually is quite common and I stated a number of possible reasons for this in an earlier answer. Your son has found that having a bowel movement provides great and reinforcing relief when associated with standing up. Are these full bowel movements? The fuller they are, the more pleasurable the resulting relief is and, the less interference with what he would rather do instead of going to the bathroom and sitting! I don’t know from your information if he is still holding partially when he goes while standing. If so, he would have smaller accidents, but then maybe several times a day? This could represent a move toward constipation and a very resistant form of soiling. An enlarged and weakened colon could result. This could mean more frequent accidents or large toilet clogging stools. Whatever is going on, he is NOT going on the toilet stool and likely is bathroom avoidant. If he is made to sit on the toilet stool for periods of 5 or 10 minutes or longer, my guess is that he would hold and then become increasingly backed up and constipated. This could turn into a real contest of wills between you and him. Sweet reason and your logic will be ineffective with him. Let’s face it, logic does not always work well with teenagers either!

He is not quite three-years-old and thus does not meet the diagnostic criteria for Encopresis as he is not yet four-years-old.  Your solution of diapers might not be bad as a temporary solution. But, this could lead to diaper dependence which is becoming increasingly common in our culture. Of course, diaper manufacturers and laundry services love this and are forever improving and marketing their products! Perhaps this cannot be avoided, but it could delay a conflict with your son to a later time when you do demand toilet stool sits. If he starts holding and becomes constipated, you may have to go the pediatric route of “top down” oral stool softeners and toilet sits after meals to minimize blockage. For some children this approach can result in more frequent accidents. In any event, at this time or later, you might try just two or three minute sits at most about 10 minutes apart 3 or 4 times following meals instead of the typical block of 10 minutes currently popular among pediatricians. I would recommend using a cheap plastic egg timer hour glass so that he can actually see time pass and know that he is freed up when the sand runs out of the top compartment. Young children live in “Nowland” and any time requirement that is not represented well is equivalent to “forever.” If he fights you and shows strong resistance then you may be setting up a real contest of wills resulting in establishing a bad holding habit. If that happens then you may have to go to my Soiling Solutions® (SS) as set forth in the Clean Kid Manual (CKM) described variously on this website. I generally do not like to see my protocol used unless there are really strong indications of holding, toilet refusal for poo, and negative emotional reactions to sitting demands in a child under 4 years of age.  Also, parents who tend to be very reluctant and anxious about using suppositories and enemas during a well-defined daily treatment hour will benefit from the SS Parents Forum that comes with ordering the CKM.

You are doing very well to be concerned with this pattern of behavior this early. There are way too many parents who delay overly long for years which can lead to permanent damage of the colon requiring reliance upon suppositories and enemas for the rest of their lives. I wish you and your son the best. 

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New York mother with a 5-year-old child, with mild autism, who is displaying severe holding behaviors, and is terrified of suppositories and enemas ... and she has been told by a Gastroenterologist not to use them anymore!
October 4, 2011

Question:

My five-year-old son is mildly autistic and severely verbally apraxic (he does not speak). I struggle with deciding if he has Encopresis or not ... he is DEFINETELY aware of when a bowel movement is coming. He will sit on the floor with his hands on his anus and try with all his might to hold in the movement. He is successful in doing this. He will produce about 8-10 teaspoon size bowel movements a day but only in his underwear. I try sitting him on potty but it just doesn't happen at right time. He is terrified of suppositories/enemas. My one visit to G-I informed me not to do these anymore. He was on Miralax but he went so often and school was finding it bothersome and unsanitary that I was kind of forced to take it away. He still continues to have bowel movements in same often tiny manner. Do you think he has Encopresis if he is aware of movement coming but just has the strength to hold it in? I always thought it truly is a control issue for him due to his autism. What can I do? We have gone on this way for over a year and it is trying on all of us. Thank you for your time and attention in this matter.

Dr. Collins’ Answer:

If he is soiling his clothes or other inappropriate places at age five and does so (just once) for each of 3 or 6 consecutive months (depending on the diagnostic classification system being used) with no organic cause, then he has Encopresis. Since he has seen a Gastroenterologist (GI doc) and you describe severe holding behavior it certainly appears to be Encopresis which is a “functional” medical disorder. Your GI doc was right to instruct you not to use suppositories and enemas (S&E) if they are not utilized in a rational program where they are used to transfer his voiding to the toilet stool and to also desensitize him to his high anxiety about voiding. The GI doc was concerned about his fear, but is not sufficiently informed that the most effective therapy for anxiety is what is called exposure therapy used for many anxiety disorders. Basically, your child is very anxious about anything going in and anything going out! As you use S&E as simple “primers” in a rational program then he will become less fearful of something going in and poo coming out. Until the Soiling Solutions® (SS) protocol was invented there really was no readily available home and manual based program to condition the child to have successful bowel movements on the toilet stool.  I do not see the autism and apraxia as an issue for success, especially if his receptive verbal comprehension is adequate.

Suppositories and enemas are readily available off the shelf in many pharmacies and stores. They are safe and very effective for initiating successful voiding. The children are invariably happy and excited about a good poop with the resulting relief. The biggest barrier for their use is our culture. It is very concerned about this sexual area of the body, offensive body wastes, and the potential for child abuse using an invasive technique. This does not appear to apply to eye drops (say for pink eye) or for insulin or inoculation injections. They are “invasive,” but do not involve the sexual area of the body! The eye lid is a sphincter like organ that operates just like the anal or urinary sphincter and we can learn to tolerate eye drops and contact lenses. 

GI docs are not all powerful and authoritative. They can be intimidated. I know some that hesitate to mention my program because of the parent’s horrified reactions to their suggesting the use of S&E! One parent called a GI doc a “poop nazi” with the mention of S&E and she was wounded by that strong negative reaction. Also, to help parents accept a legitimate medical procedure and to get over their initial reluctance can take up a lot of their time when they have patients waiting. You are from New York and there are two Encopresis listings in your state under the home tab at www.encopresis.com that have used my manual and the associated parents’ forum that comes with its purchase. Good luck, you and your child really should not have to live with this issue.  It is so damaging for everyone. You will have to be very strong and, well, a parent!

A Minnesota mother of a 6.5 year old daughter is losing hope after trying out many interventions with professional advice and many personal insights.
September 30, 2011

Question:

We have a 6-1/2 year old daughter who is strong willed and can be very stubborn at times. We began potty training at 2.5 years old. Everything was going great until we suffered an infant loss. We thought it was a control issue at first due to the trauma, then she was diagnosed with constipation and finally she was diagnosed with severe stool withholding. We have been to a psychologist, GI specialist, and have tried natural remedies like high fiber, lots of water, etc. Currently, she is on very high doses of Miralax (8 adult doses daily at times). This has severely disrupted all of our lives and has been very consuming of both our time and emotions for all involved. Interestingly, when she starts wetting herself more frequently there always seemed to be an infection of some kind happening in her body (strep/staph). The day after her first dose of antibiotics she begins to stay dry and also has regular bowel movements. Her doctors seem to think the antibiotics are releasing the stool, therefore releasing the pressure on her bladder. I agree with this to some degree, but am not satisfied that this is the only answer. Usually, at about three week mark after the start of taking the antibiotics, she goes back to her normal cycle of soiling herself repeatedly throughout the day. She will sit in it until we notice the smell. She is humiliated and embarrassed even though we do not shame her. I am concerned for her emotional well being at this point because she is so much happier and vibrant when on antibiotics or having a healthy stretch of good bowel movements. She will ask if she can be put on antibiotics because they make her feel so much better. We cannot seem to find the right dose of Miralax to keep her emptied and stools the correct consistency that is manageable. We are losing hope of this ever ending. Could you offer some insight on this for us? Would your product help us?

Dr. Collins’ Answer:

You have so many observations in your excellent background that I will briefly address each in passing before giving you some direct advice. I believe that information and adding insight to the basic problems you raise will be of help for you to proceed and do what you have to do if you want to get out of your present impasse.

Yes, strong willed and stubborn are features of a child that can set up a conditioned holding phenomenon. Children are not “blank tablets” which we just program. Their “hard wiring” for characteristics like strong will and stubbornness can be of survival value for their move toward adult independence. The loss of a sibling may also have added to the problem because of stress in the home situation affecting her physically and emotionally. The present dominant use of stool softeners like Miralax which biases toward soft, liquid stools is a rational approach and may work for about 50 percent of children in a year’s time. But, complications do result for those who do not respond. Liquified stool is much more difficult to recognize and it is more likely to squirt or ooze out with sneezes, changes in posture, physical exercise, fatigue, etc.  Also, it may be more difficult to clean up and linger in the anal-urethral region where urinary tract infections are more likely to occur, especially for girls with the shorter distance between the anus and the urethra than for boys. Your observation about antibiotics giving relief is commonly observed, but not a solution because it also kills the good bacteria in the gut. A good prevention device for urinary tract infections, sores, and rashes is the bidet inserts that you can now see on the floor of large home supply stores. They can be installed on your existing toilet stool. They also can stimulate a bowel movement and relax the External Anal Sphincter (EAS) with which she is holding back stool.

For many of these children a conflict occurs between releasing and holding back a bowel movement. This can be quite complicated as there has to be a timely and exquisite coordination (synergy) of the pelvic floor, the EAS, the abdominal muscles, and the levator ani. This is what happens with holders and it is called dysnergia. These children can even hold back softened stool and get backed up slowly over time even as they may have partial bowel movements. Biofeedback, which has to be done in a clinic setting (with balloon insertions for pressure recordings or surface muscle potential measurements), may be tried. My Soiling Solution® SS protocol uses a daily treatment hour with carefully sequenced times and suppositories and enemas which can be done in the home. The SS approach really requires the purchase of the Clean Kid Manual (CKM) and following a special SS parents forum for sharing insights and support. The just revised CKM includes chapters for treating daytime and nighttime bedwetting. About 98% of the parents on the forum are mothers, and I call you guys the mama bears!

There are indeed solutions and clearly you and your child are of a mind to act. Good luck!

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New York Mother with a seven-year-old daughter who is both bladder and bowel incontinent.
September 27, 2011

Question:

I was wondering if you could help my daughter (7.5) with her daytime wetting and occasional stool leaks.

Dr. Collins’ Answer:

Very likely I can help, but you are the one in the trenches that will have to do the hard work. I provide the most and best information that I can to help you to succeed.The two new chapters in the latest Clean Kid Manual-5th revision (CKM-V) do indeed deal with daytime and with nighttime bladder control in addition to encopresis which you noted for your child. Encopresis is defined as fecal incontinence after organic causes are ruled out by a physician. I am assuming that by this time you have had your daughter seen by a physician. However, I know that this is not always true and would urge you to see a doctor if you have not.

My manual was written initially for this horrible problem of Encopresis, but it gradually emerged that wetting was closely associated with Encopresis. Wetting is associated with being severely backed up with stool, an enlarged colon, and added pressure in the abdominal area, which is why I added the two new chapters. I had earlier written a manual for bladder problems alone because I had been widely recognized for my work on validating the bedwetting alarm. However, the sales were so poor for that manual that I gave up on it and focused in on Encopresis which was viewed as much more distressing by parents, children, and schools. Combining the two disorders for treatment in one manual eventually made a lot of sense. When the soiling is solved the wetting often disappears, but the wetting issues can continue for some children and may have to be addressed in their own right.

Colorado mother with a 6.5-year-old daughter with Encopresis and “… no end in sight.”
September 23, 2011

Question:

After successfully being day and nighttime potty trained at three years, my daughter started having daytime enuresis at 4.5 years old. Initially the pediatrician told us to discipline her for the wetting but after 4 months of no progress and nighttime Enuresis starting, we consulted a urologist. An xray diagnosed constipation and she was put on Miralax. A month later we had no progress. A second specialist who focused specifically on Enuresis again diagnosed her with constipation. We did a 'clean out' and then followed a regimen of daily laxatives and Miralax. When it was time to give my daughter responsibility for going to the bathroom without reminders, she failed and started wetting again. A visit to a third specialist yielded similar results with a cleanout and a daily regimen of laxatives with a slightly less disciplinary approach. We reached short term success before she started soiling herself. We were then passed on to a GI specialist who instituted a very aggressive cleanout and more aggressive laxative regimen. This was accompanied by 3 'toilet sits' per day after meals for 10 minutes. For the past 4 months, my daughter has had at least one bowel movement every day. But the stool leaking has started again. We have been told to increase the dose of Ex-Lax. She is also under psychological counseling which entails “re-potty training” her. I now wonder if a food allergy is causing the constipation. There seems to be no end in sight.

Dr. Collins’ Answer:

Constipation is often behind daytime and nighttime bladder control issues. I have added two new chapter in the Clean Kid Manual (CKM-V now in press, available soon) on both daytime and nighttime bladder issues because urinary problems can persist after the constipation is properly addressed. The parents on our Soiling Solutions® (SS) forum, which comes with purchase of the CKM, I have learned that wetting is a sign of an impending relapse to slowly backing up again (exactly your situation). 

The SS program is, in essence, a retraining program to foster successful toiletings ON THE TOILET STOOL. It uses suppositories and enemas in a particular sequence and with unique timing (including much shorter sits) for one treatment hour each day. If your child has an enlarged colon which can result from a severe holding habit it could take quite some time for normal self-initiated toileting to take place. But, at least, she would be soil free while doing SS. 

Do not start down the long and torturous, speculative path of food allergies without first addressing the real problem of holding and incomplete bowel movements. I have seen parents who have delayed effective treatment for years chasing a magic diet.  Food allergies can be more effectively revealed, if present, if you have daily successful bowel movements where you can assess the stools and diet together as you proceed. It is remotely possible (five percent or less) that those allergies could have triggered holding behaviors, but they are not the basis for a solution to that holding problem once it gets started. However, the knowledge you gain with SS can speed up recovery as you do elimination trials or add items to the diet. Advise the counselor to study all of the information on the www.encopresis.com website including my medical journal article at www.encopresis.com/Articles.html.  He/she is more likely to have heard of my research with the bedwetting alarm.  If he/she is just doing all kinds of behavioral reinforcement strategies they are very time consuming, frustrating, and unlikely to work when you have an overlearned holding issue. With SS 90 percent of children are not soiling within 2 weeks or less. I would be happy to talk with him or her unless they are scared of becoming the poop doctor for Colorado. He/she should also order the manual as it addresses all manner of issues that come up with Enuresis and Encopresis. Also, he or she will learn much from the parents which includes parent physicians, nurses, and psychologists on the forum. I hope that he/she will not be insulted!  Dr C.

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A United Kingdom 10-year-old boy, demonstrating strong holding behaviors, may have been helped with great insight and action by the mother.
September 20, 2011

Question:

My son has a history of urinary tract infections from being a baby, due to one of his kidneys being smaller than the other. He was under a specialist until his kidneys were grown and the reflux had stopped. He was seven years when discharged. Also when he was a few weeks old he has problems passing stools, he got very constipated and there was blood around a stool. I was given a lubricant and a metal rod which was designed to stretch the hole to enable him to pass them more freely. I used that for a few months and returned it to the hospital when it had done the job to prevent them having to risk cutting muscle tissue to enlarge it. I didn't have problems with my son until i separated from my husband when he was about six-years-old. He sits on the floor and tries to push his poo back in as he can't stop it from coming out. Recently he has started to do this more regularly, and even though he has a good diet and is generally a sociable enough child, good at school and plays out with his friends, etc., he seems to be holding it more. At first i ignored it thinking that it is just a way of manipulating situations and seemed to be using it to his advantage so thought not making an issue would help it go away. He tends to go off into his own little world a lot recently too, not hearing us tell him to do things unless we go right up to him and get his attention first. An incident tonight has caused me to worry as we were at his sister’s house and she has a three-year-old little boy. The child had been in the bath and was wearing a pull up for bed and my son had been alone in the room for about ten minutes. When I saw him I sent him to the toilet as he looked as though he was pushing poo in. About 10 minutes later my boyfriend noticed that he had stood in a stool, must have been a hard one, but i really think that he must have tried to tuck it under the sofa, therefore he had pulled it out of his pants, hoping that we would think it was the younger child. When asked, he answered "it couldn't have been me" but he wasn't too sure I don't think. I believe it's mental, what do you think?

Four days later the mother sent in these additional observations in response to a brief note from me:

I contacted you recently with regards to my son, who was holding in his poo and then seeming to let it out in the most awkward situations and denying it. Since receiving your email back clarifying that you didn't think it was a mental problem, i worked with this and had a long hard talk with my son to try to make us both understand why this was happening. He explained that it hurt him sometimes when he pooed and when I explained that it will if he holds it in because it will get harder and heavier and he must try to poo at least once a day to stop this happening, he has seemed much better. I gave him a spoonful of Lactulose and told him that would make it easier to pass and he seemed generally pleased with himself as it didn't hurt and since I am checking that he goes once a day and i need to see it to monitor whether he needs lactulose again or not. Thank you for your advice on this matter. I was relieved to hear that he was not urgently in need of counseling, just needed us to be more patient and realize how embarrassing this was for him.

Dr. Collins’ Answer:

This young British lad demonstrated severe holding behaviors, and some deception, which concerned the mother about an accompanying mental disorder. My response clarified that his behaviors were basically normal under the circumstances. The mother subsequently questioned her child and he disclosed fear over bowel movements because of painful passage. This is likely the most common onset for Encopresis which typically results from constipation associated with painful bowel movements.  This shared insight coupled with a stool softener appears to have lent sufficient insight that they may have solved the holding issue. This is an ideal solution, but it is very, very far from typical because the holding can be very resistant to change once it has formed into an automatic habit which can have a life of its own even when the original causes of painful stools may be solved. The use of stool softeners in a top down approach is the primary pediatric intervention for encopresis and has about a 50 percent success rate over the course of a year. If this approach fails then the dominant home-based default approach is my Soiling Solutions® bottom up protocol using rectal primers (OK, suppositories and enemas) which specifically fosters the successful habit of successfully voiding on the toilet stool on a daily basis. The mother indicates that she will monitor her son closely on a daily basis. That is very well indicated as these children can be very subject to relapsing with notable changes in their environment.

I wish this mother and her son the best and was very happy to lend then some insight and relief.

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A Michigan mother with a five-year-old daughter who has a history of relapses for Encopresis and Enuresis
September 16, 2011

Question:

My 5-year-old daughter will periodically have bowel movement accidents in her underwear. It seems to happen when there is some stress or major transition. Examples: Father and I separated when she was 2, so she regressed in potty training. Had to completely retrain. Then her father remarried and moved several times, and with the marriage and every move she would have bowel movement accidents for a while. Well she has been doing well for about 6 months now, but with kindergarten coming up she has started what I think is with-holding her bowel movements. She has about 3 accidents a week, usually just a smear, and then takes very large, stinky poos. She says she doesn't feel it until it is too late. So I am not sure if I should not do anything until she gets used to kindergarten....because the pattern is once the stressor is gone, she goes back to normal. She does still have periodic bed wetting issues as well. I am not sure if this is related or separate issue. She just sleeps so soundly that I can vacuum in her room and not even wake her. So anyways, is this periodic bowel movement accident issue something your program would help?

Dr. Collins’ Answer:

Using my program by ordering the Clean Kid Manual (CKM) and joining the parents on the Soiling Solutions® (SS) forum is a judgment call for you to make. I will present some ideas to you and others to consider in making a decision about what to do.

The pattern of spontaneous recoveries for your daughter from both encopresis and enuresis is wonderful, but obviously disconcerting for the periods that she and you suffer from her relapses. The manual may help to speed up and better consolidate recovery from her relapses for longer lasting results. Encopresis and Enuresis are often correlated with each other.  The additional back up of stool or constipation creates added intra-abdominal pressure resulting in conflicting body signals and makes bladder accidents more likely. The fecal accidents should be addressed first before the bedwetting. Once the soiling is treated the bedwetting may recede. If it persists, then it may need treatment in its own right. The new manual, in its 5th revision, is now “in press” and should be available very soon. It addresses both Encopresis and Enuresis for the first time. 

I received a lot of professional attention for validating the bedwetting alarm which has proved to be the best most effective, long lasting solution for enuresis and it is recognized as such by leading medical authorities. However, modern parents tend to be more reluctant to apply it for fear of disturbing their child (and themselves) and our culture is also more tuned into and trusting of oral medications! So if you do employ the alarm recommended in the manual prepare to lose some sleep! 

Encopresis is a much more disturbing experience for parents and the child than bedwetting. Parents can spend years with reinforcement charts, food allergies, and various alternative treatments to no avail. You are likely right about the stress factors affecting your child’s bladder and bowel control. Starting school is a very significant life event and the second most likely event for the initiation of Encopresis. Other significant factors like divorce come in third. The first most likely onset is toilet training itself which can be associated with the child’s temperament, rejection of giving up diapers or pull-ups, fear of the toilet stool itself, a painful passage of stool, etc. However it starts, Encopresis takes on a life of its own. It can be very resistant to current dominant top down strategies of using oral stool softeners and laxatives. Laxatives are actual stimulants triggering peristalsis. That strategy is viable and can result in a 50-60 percent remission of Encopresis over the course of a year. The major in-home alternative to the top down approach is the SS protocol. However, to be honest, while it has garnered a lot of professional attention, it is controversial because it uses a bottom up strategy of using suppositories and enemas (S&E) off of drug or grocery store shelves.. 

The advantage of using S&E is that they are administered at the problem where the problem actually exists. They promote the recognition of voiding urges and then successfully responding more quickly with a voiding response WHILE SITTING ON THE TOILET STOOL. I suspect that many of these children are very stool avoidant and actually have been trained to hold when told to sit. It may well be that the use of stool softeners for some children could well promote the holding response as a very bad and strong habit. SS helps to break the habit of holding to release. The program is designed carefully with an administration sequence during a daily treatment hour which empties the child out, keeps them accident free, and forms a pattern in time of shorter treatment hours and a more reliable connection with voiding when needed. If this is done the SS way then the child takes over the process and becomes S&E free. You can read the basic approach at www.encopresis.com/Articles.html, but do not try the treatment on your own without the CKM and your fellow mothers. Fathers are very, very rare on the SS forum!

Kansas mother with an almost 4-year-old boy who has learned to never, never poo on the toilet ... upsetting both mom and dad who have different approaches to the issue.
September 13, 2011

Question:

My son is three, and will be four, in October. We have been working on potty training for over a year. He will successfully urinate in the toilet and not have any wetting during the day but, he is constantly having small, very sticky, very smelly bowel movements in his underwear. It almost seems like he is unaware that he has done it. It is very hard to clean up as it is so sticky and it is causing irritation and redness on his bottom. When we asked him why he poos in his pants he says "because my butt is cold". I really don't know what that means. We have tried to have him sit on the potty but he has never had a BM on the toilet. We are going through 5-10 pairs of underwear a day. Every week or so he will have a major bowel movement that is very smelly and runny. It is getting very frustrating because my husband is insistent on punishing him when he has an accident in his pants, but I don't agree with it - especially since I feel like he is really not doing it on purpose. Any advice would be appreciated.

Dr. Collins’ Answer:

“Because my butt is cold!”  What a response, cute! Hey, his bottom is bare and there is all that cold water in that noisy scary whirlpool suck hole beneath him! So, maybe it does make some sense if we enter a child’s mind. Many children can pee in the toilet while at the same time refusing to poo in it; this includes girls who have to sit for both with a bare bottom. Boys do outnumber girls with Encopresis by at least 2:1. Lots of boys hate to take the time to sit and go when the whole world is so exciting and sitting is so boring and maybe scary. Issuing commands or using sweet reason is not going to work to take care of this problem.

You might consider purchasing and installing a bidet insert which fits onto the standard American toilet with prices ranging from $200 and up with installation. This would help to make cleaning up much more hygienic and avoid the irritation and rashes. The smelly stool derives from his backing up and the rotting stool that is held in his GI tract for too long. The bidet insert might fascinate him and counter any anxiety over sitting on the toilet, plus the water jet tends to promote a bowel movement. However, there is a caution; he and the whole family may hate going anywhere else to go to the bathroom. These days you can see these bidet inserts on the floor in Menards or similar such stores. They tend to be for high end users, but I think in time they will become more common. My Italian sister-in-law loves this Japanese/American insert version better than the separate fixture they use in Europe. She uses that old Napoleon version for soaking her laundry!

I am the inventor of the Soiling Solutions® (SS) protocol which uses suppositories and enemas (S&E) in a very rational sequence during a daily treatment hour to move the child toward independent and proper toileting success on the toilet stool. But, I really do view it as a default procedure when everything else fails. This is all spelled out and explained in the Clean Kid Manual (CKM).  It is difficult to apply and the child is highly resistant to forced sits and the application of S&E in the beginning. However, they take great pleasure with relief for successful poops and their poop engine begins to work and not shut down when sitting on the toilet seat. The idea is that repeated associations with successful poops when sitting on the toilet will become established through a brain-voiding learned connection. Basically, it follows the very same principle of what happens when you use the can opener or open a refrigerator and the pets all come racing and salivating to the sound that has been associated with food. Soiling Solutions® works at the bottom end of the same GI tract when sitting on the toilet stool. This makes me the Pavlov of the bottom end and not the guy who won the Nobel Prize for Medicine and Physiology in 1904, which most college and medical students are aware of from studying the conditioned reflex for salivation. Also, research on conditioning the eyelid reflex, which is both voluntary and involuntary in nature, is very similar to what I am doing with the External Anal Sphincter (EAS). This supports the conditioning view. Children can learn to tolerate eye drops, injections, etc. by repeated exposure and comfort in a similar way.  Fear tends to activate these muscles.

So, I hope this helps. Your role as a mother is seriously challenged with this problem and you can often feel very isolated when so few people understand what you are going through. Your husband can play a very constructive role, and enhance your marriage, if he can get on board with the above suggestions. He, and you, if you feel you should order the CKM, will love the parents you will have contact with on the SS Parents Forum which comes with an order. If you try the bidet route write back and maybe we can feature your experience!  

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Seven year old Texas daughter with giant BMs and very smelly fecal leaking
September 9, 2011

Question:

My daughter, who will be seven in a week, had gigantic poops as an infant which would cause her bottom to bleed. My PedGI never took me seriously. On the advice of a friend, I put her on lots of Miralax at 18mos and that solved the problem until it came time to potty train. She trained fairly easily at about age three, but could never control the leaking. It is rarely more than two tablespoons, but it smells so bad, almost sickly sweet. We have gotten to where she is now pooping every morning, rather large ones - I am often amazed at how gigantic they are yet she claims they don't hurt. Now that school has started, the leaking is back with a vengeance. She is terribly embarrassed about it and scared of the other children finding out. I don't understand why she leaks when she is having regular BMs. She claims she can't control it, however, once there was a toy she wanted, and we said if she did not soil for two weeks she could have it. She did great, got the toy, and immediately started soiling again. She is above average intelligence, very strong willed, and very emotional. We have been to at least 3 GI's over the years and had a balloon test done at Texas Children’s about 18 mos. ago, which was normal. I thought we would have grown out of this by now and am very concerned that this will still be around when she is older :( Please help.

Dr. Collins’ Answer:

Seven-years-old and no resolution after seeing three pediatric gastroenterologists (PedGIs)! That is truly upsetting! Unfortunately, both psychologists and physicians do not have a good handle on this problem of holding and an enlarged, weakened colon that results from it. The overly strong and overlearned automatic holding response due to early traumatic pain with elimination leads to the enlarged colon and incomplete bowel movements (BMs). This leaves old and more putrefied stool behind. Imagine leaving food out on the table for several days in hot weather (say 98 degrees to replicate your body temperature) and how it would smell after several days. When enlarged, the sigmoid colon toward the end of the GI tract just before the rectal chamber is weakened and loses its strong, final emptying out action. Also, with the holding habit you have premature closure (dysnergia) and an insufficient release or relaxation of the External Anal Sphincter (EAS). Automatic, involuntary closure is what happens initially when poop, if it is formed and not liquid, knocks against the EAS. This causes the problem to persist even after temporary remissions such as you observed when she was strongly motivated to empty and probably hold even harder to prevent accidents. That can only work for so long as more stool backs up and enlarges the colon even more! This is really a vicious cycle.

Now most pediatricians and PedGIs will diagnose and address encopresis at 4 years of age. They prescribe stool softeners like Miralax and Lactulose with the former now dominating. Some may even add a “kicker” of a laxative (colon stimulant) to promote complete elimination. Really, that is quite a rational approach for children who are more compliant, tolerate toilet sit demands, and respond to behavioral reinforcement approaches. That works for 50-60 percent of children in a year’s time, however, when it does not work it is because these children are very bathroom avoidant, learn to clamp up and are fearful of relaxing the EAS.  Now the softened stool for them is more likely to leak with sneezes, coughing, jumping, running, and the like. Parents get upset and guess what?  Well, these children are not dumb! They learn how to hold harder and harder, enlarge their colon more, and now a toilet sit becomes the signal to hold and something to avoid because it means that they are afraid ever, ever to release there. If they are initially somewhat busy, stubborn children and you want them to do something, well guess what? Dun wanna, ain’t gunna! What a vicious cycle and everyone is caught up in it. So, do you reverse and replace this vicious cycle with a virtuous cycle by sweet reason and persuasion? Here words will fail and only parental actions will work, only later to be followed by grateful words and “insight” on the part of the child. Incidentally, suggest to your child that she will have to poop for the rest of her life—I will bet you will see a great deal of consternation. Reality can be so mean!

I have in prior answers jokingly invoked waiting for the “continence fairy” to show up to transform your child.  Basically, these days that is what too many doctors advise when their “top down” approach does not work. I am controversial with the Soiling Solutions (SS) protocol “bottom up” approach that must be followed using the Clean Kid Manual (CKM). Proper sequencing and timing during a daily treatment hour leads to enhanced voiding stimulus recognition and then a successful BM. The balloon study showed that this mechanism was intact for your child. The kids fight and resist and become hellish drama kings and queens in this OK Corral situation of inserting a suppository or/and enema.  Really, this is not unlike getting an insulin injection or inserting eye drops for pink eye! It is just that our culture has become so defensive about this sexual area of our body and issues of child abuse. This even includes many physicians who have become intimidated by horrified parental reactions and cultural fears. I am hopeful that a foreword by a New York state PedGI in the new CKM (just available—make a request and I will attach a copy to any readers) will help medical personnel to be more comfortable with a perfectly legitimate medical intervention. DO NOT ORDER THE CKM if you object to suppositories and enemas which are really just “rectal primers.” Maybe the continence fairy will eventually show up or you can learn to live with fecal soiling by teaching your child how to wear surgical gloves and clean him/herself up indefinitely. I have actually heard of pediatricians who assure parents that their children will not go to their Senior Prom with this problem. Your choice!

Australian mum and 7-year-old son “stuck” on the “top down” approach to Encopresis.
September 6, 2011

Question:

My son has been soiling in his pants since he was toilet trained, have found that he is quite ok with leaving dirty underwear on, have had xrays which showed blockage and was given a treatment plan to disperse that with laxatives ... and not sure if food is causing this also have seen a childhood therapist which she found it not to be anything to do with his childhood. Also try making go at same time everyday which usually develops in to tantrums..

Dr. Collins’ Answer:

You have certainly followed highly approved approaches to the issue of Encopresis. The physician’s use of stool softeners and laxatives (stimulants to induce peristalsis) is the dominant approved medical approach for encopresis. It is a rational approach based on the notion that it will make bowel movements more frequent and keep the child emptied out. In addition, it theoretically allows the colon to return to normal size and function so that the child will begin to recognize his bowel urge stimulus and associate it with the voiding response. It has a likelihood of working as predicted for 50-60 percent of children over the course of a year. His childhood therapist examined his history, saw, and ruled out likely causal psychological events. Indeed, the onset of almost all Encopresis is generally associated with very minor initial causes leading to stool sitting avoidance. However, once triggered, the withholding tendency becomes very, very fixed and robust. It is not subject to sweet reason, reinforcement for sitting compliance, or punishment. A vicious cycle gets started and you both become “stuck.” This is why when I was invited to your country (Perth area) some years back on the strength of my previous work with bedwetting I began to think more about Encopresis which caused much stronger conflict issues for parents and children. Something had to be done about the frequent impasse that had developed for professionals, parents and children. 

Soiling Solutions® (SS) and the Clean Kid Manual (CKM) were the result. The real issue for your child at this time is that he has formed a very deep and unconscious “bad habit” of holding and stool avoidance. He literally holds on the toilet sit and has to learn to release and go on the stool. SS is not an upfront go to solution for Encopresis; it is a default procedure because of the general resistance to the use of suppositories and enemas (S&E) which are a part of a conditioning process to associate successful voiding with sitting on the toilet stool. It is a grave and mistaken belief that SS just uses S&E for daily clean outs in a mechanical fashion.  SS assures that real training takes place during a daily treatment hour at close to the same time every day to foster a successful stimulus (bathroom, sitting, voiding urges) and a voiding response connection. This can all be done in the safety and trust of your home setting with the help of the CKM and parents on the SS forum (includes Australians). Many parents have had to proceed without the endorsement of their physicians, but should keep them “on the back burner” so to speak. Even though I have published in a medical handbook for primary care and wrote a medical journal article I have not been an effective persuader as a psychologist. A foreword in the upcoming revised CKM-V manual has been written by a Pediatric Gastroenterologist. Maybe that will help in providing a breakthrough for SS in medical circles. You parents are also potential breakthroughs when you report back to your physicians. Do not delay any more, get your original child back! You will be his hero.

A Canadian mother wanting to know how to “convince” her 5.5-year-old child to use the toilet instead of pull ups:  A basic misunderstanding?
September 2, 2011

I've come across your website and I'm not entirely sure that purchasing your SS will help my situation. My son DOES come to me when he needs to have a BM however he will only go in a pullup. Has never had a BM on the toilet. Does your program include information about HOW to get my son to feel comfortable sitting on the toilet seat? I think once he has a few BM's on the toilet he will be okay with it and will continue. He does not have true encopresis only an aversion to the toilet. How can I convince him to stop pooing in his pullup and use the toilet instead? He does not hold in his BM's, he always tells me when he needs to go. Do I need to FORCE him to sit on the seat?

Dr. Collins’ Answer:

This mother has very good insights mixed in with some basic misunderstandings. Encopresis is simply defined as soiling in inappropriate places without an organic cause beyond age four years. At his age pull ups are inappropriate to void in, thus he meets the definition for true encopresis. Encopresis is a functional medical disorder without having to have a physical disease basis. It is medical in the sense that a physician has to rule out possible likely organic causes and it definitely involves a malfunction of the mind-body connection. She is likely at least partially right about the cause in suggesting an aversion to the toilet seat and his ease of going into his pull up. It is wonderful that he does recognize his fecal voiding urges and can go in the pull up. The pull up-voiding connection here is well-established and likely soiling has not been an issue because of it. However, it really is only a band aid approach as sooner or later he does have to transition to making a stool sit-voiding connection.

So the mother is caught here like many parents who have overly relied on pull ups or diapers for too long. This is increasingly common today with greater delays in toilet training with hard-working parents and an overabundance of disposable diapers/pull ups. The marketers have even come up with larger and larger fashion designed denim diapers with cute TV ads! Pediatrician, Dr. Brazelton, is a major spokesperson for delaying training until the child is “ready.”  However, in my opinion, it comes down to an old cigarette advertisement, “I’d rather fight than switch (brands)!” So, “How can I convince him to stop pooing in his pull up and use the toilet instead?” Go ahead tell a smoker to stop smoking and I suspect you will get a similar result! Sweet reason and logic simply will not work for many situations and this is one of them as you have undoubtedly found out. I have found it as well in my practice and research. Frankly, you have to induce the right stool sit-void connection by causing him to go successfully, repeatedly on the toilet stool using the Soiling Solutions® approach detailed in the Clean Kid Manual and reinforced with suggestions and support by the mothers on the SS Parents Forum! Yep, it requires gentle, determined force to use suppositories and enemas in the daily treatment hour and short sits on the toilet stool. No doubt about it! But, these children are invariably excited and happy with successful toilet sits even after all of the drama of inserting a suppository and/or enema as required. Success breeds success and he persuades himself as he takes over the stool-voiding connection.  But all of this has to be done right to assure success and not worsening the situation. Done properly the mother becomes a hero in her child’s eyes.

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An Ohio mom with a 6-year-old boy stuck on Miralax and  pull-ups with accidents in the middle of the night
August 30, 2011

Question:

My son is toilet trained. However, he was a very constipated child and realized that too much cheese and dairy (minus the probiotic yogurts) contributed to this constipation. The pediatrician has suggested Miralax and sitting on the toilet for 10-15 min after each meal. We have done this consistently for weeks and my son is able to hold and control when he will have a bowel movement. We will put him on the toilet before bed and he will usually not go and proceed to have a bm during the middle of the night. It does not seem to bother him that he wakes up poop in his pull up. He also goes through periods of "skidmarks" in his underwear during the day. I know that he has to have a bm by the way he walks and I insist he sits on the toilet where he promptly holds it and proceeds to wait till he is sleeping. I am at a loss. I have spoken with my pediatrician who prescribed the Miralax and daily sits on the toilet, but this is not working. I think I am more frustrated than he is. I feel that at his age he should not be in a pull up, but yet I cannot afford to have something to clean this mess up during the night. As an additional note, his stool is extremely smelly. I have never smelled anything like it. I would appreciate any help with this situation.

Dr. Collins’ Answer:

The diagnosis is Encopresis as defined by soiling in inappropriate places without an organic basis beyond four years of age.  The skid marks or tire tracks are ample evidence of overflow incontinence and is often confused by parents with incomplete wiping. This is usually associated with overly softened stool caused my many popular stool softeners urged by Pediatricians today. It will ooze out or the children with passing gas or escape with a sneeze, cough, jumping, or other activity. Sometimes parents describe pebbles. Other parents may encounter toilet clogging bowel movements. Pediatricians have the idea that the softened stools will result in easier passage and more acceptance of bowel movements in time leading to shrinkage of an enlarged colon and normal stimulus recognition of a filling sigmoid and colon. Actually that can work for some children over the course of up to a year. However in others I think it may result in training for holding even more strongly and not associating normal bowel movements with sits on the toilet stool. Indeed, it is my opinion that toilet sits for these children may actually condition holding which is the opposite of what you want! This would appear to describe your child’s current status.

The very smelly bowel movements derives from the holding and the food stuff rotting and putrefying well beyond what would be normal (“fresher”) with more frequent complete eliminations. Accidents in sleep are really fairly rare. The nighttime accidents are not complete enough to result in accident-free days because there is much backed up stools and of course he continues to digest the prior days’ meals producing more stool. The nighttime accidents are not surprising. His External Anal Sphincter may become very relaxed allowing a partial bowel movement in REM sleep. The incomplete nature of a bowel movement may be because of a stretched out and weakened colon or because even in sleep his holding reflex is prematurely activated.

The essential idea of the Soiling Solutions® protocol (SS) is that it focuses on a particular time of day for the treatment hour where complete elimination is going to be triggered by the use of timed sits and the use of suppositories and enemas (S&E).  This results in a dramatic reduction of accidents (including nighttime ones) while at the same time resulting in the daily success of going on the toilet stool. The child slowly or some fairly rapidly take over their own voiding body function as the association of going on the toilet becomes better established by repetition in a normal learning curve. The techniques and timing sequences are only available in the Clean Kid Manual (CKM) and supplemented by the help of the mothers on the Soiling Solutions® Parents Forum. Too many parents and physicians do not understand the SS protocol and may claim knowledge of it without the manual. The use of S&E without the timing and other details set forth in the CKM would be a very basic error.

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United Kingdom Mum with a 4-year-old daughter who was infant potty trained and then “lost it.”
August 26, 2011

Question:

My daughter used a potty for poos from 6 months old (I used to sit her on the potty at appropriate times - she wasn't independent, obviously). Before she turned 2 she stopped pooing at the nursery she attended 3 consecutive days a week. Then she started leaking. She was toilet trained before she was 2.5. She always did her 'real' poos on the potty with no fuss, no straining and no dry stool but between bowel movements she would leak a bit without realizing. I saw a doctor when she turned 3 (a year after the problem started) - he advised me to put her back in nappies because 'it was easier for everyone'. I didn't. He prescribed fibrogel which had no effect. Then we tried lactulose which I was told would 'guarantee a bowel movement in the morning'. We used it for a month and didn't get a single bowel movement as a result - just the usual every 3 days, soft, easy to pass, no fuss on the potty, enormous, stinky but with leaks the day before. Then Senna - also didn't change anything. Tried to manage it by making the poo more solid hoping that she would have more control. Ended up cutting wheat and a few other things. Poo was formed for the first time ever and became more regular, leakage stopped for a week at a time, but even the tiniest slip up resulted in no poo for 3 or 4 days and lots of leakage. At age 4 a new doctor said she was definitely constipated and put her on Movicol. We did the ramping up week - 2 sachets for 2 days, then 4 for 2 days, then 6 for 2 days. On the worst days we went through 20 pairs of pants with lots of poo in each. Now we're supposed to find a stabilizing dose that guarantees one poo a day - but 1.5 sachets result in leakage and accidents where she just can't get to the toilet in time and 1 sachet still produces a cow pat of slop but not every day. I think she has a mega bowel, but she's never had to strain for a poo, she goes happily by herself, but still the leaks... What do you think? Thanks for your help.

Dr. Collins’ Answer:

The infant potty training (or, elimination communication) movement has demonstrated that these children gain bladder and bowel sphincter control much earlier than they are given credit for by most physicians. Basically, the mothers are very observant of the children and catch signs (usually facial, restlessness or becoming very quiet, hiding, etc.) that they need to void and then place them over a receptacle and give them a signal cue for them to void! This works and the cueing sounds become connected to the voiding response. My hope was that, in general, this training would reduce the incidence of encopresis. Statistically that could still be true. This case supports that the external parental cueing may not sufficiently transfer to the child’s own internal response to voiding urges. Or, that a relapse can occur by becoming overly resistant to voiding, building up and resisting pressure signals, and developing an enlarged colon for very minor reasons. Some leading experts are now using the term dysnergia to describe the dominance of the holding reflex arc over the voiding reflex arc. This can also account for incomplete bowel movements leading to continuing build ups of even softened stool and leakage. 

The standard typical pediatric approach is to make the stool very soft which all too often only makes leakage and accidents easier which in turn could lead to more efforts by the child to hold when this happens. In some instances I am sure that this results in conditioning the child to hold even more and making the holding habit stronger. Of course the parents become upset or disappointed. It could work, but I think it is really a 50/50 proposition and it should be abandoned if it does not work after 6 months to a year, at the most! Going to nappies is a band aid approach which only makes a later switch to proper voiding on a toilet stool more difficult. The children tend to see nappies as very convenient and they help them to become even more used to accidents. In fact I think that this has become an increasingly wide cultural issue as toilet training has been much more delayed in the last generation or two. This has been aided by the intense marketing of disposable and larger nappies for busy and stressed parents. The children are being exquisitely and unintentionally nappie trained! The heck with toilet stools!

So how do you promote a proper voiding reflex with the cue of the bathroom and sitting on the toilet stool? There is biofeedback discussed in my August 2, 2011 Q&A response and the Soiling Solutions® (SS) protocol which I developed and is set forth in the Clean Kid Manual (CKM) using suppositories and enemas (S&A) limited to a just one hour focus once a day. Basically S&E are rectal primers that assure earlier sensory recognition of a filling colon and it triggers a competent bowel movement. If the protocol is carefully followed the child eventually makes the transition to self-recognition of voiding urges and responding appropriately with a voiding response to them when sitting on the toilet stool. That is the association that has to be built. Current approaches, if anything, lead to reinforcing over and over again the holding response which is the very opposite of what you want!  Interesting is it not, that many of these children may be being trained to HOLD ON THE TOILET STOOL! That is why they get backed up even with soft stool. If you order the CKM be sure to educate your physician. The parents on the SS Forum, which includes UK mums, will be glad to see you and help you out!  

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Florida 5-year-old strong-willed boy who has periods of being soil free, but is thrown off by changes in his schedule.
August 23, 2011

Question:

My son is almost five and struggles with pooping in his pants. He is very strong willed and has displayed some mild control behavior problems which has complicated his potty training. Last year, after some success potty training, my son began pooping many times a day - so much so that we went back to diapers and we went to his doctor. He referred us to a GI who started my son on Miralax. We waited for six months and potty trained again. It did not go well, but he has made progress. He can go for weeks at a time with little or no accidents, but then will have multiple poop accidents a day for days and days. I have weaned down the Miralax from 4 teaspoons a days to 1 and do not think that my son is really constipated. The pattern I see is when my son's day is on schedule, he poops after lunch and everything is fine. It is when he has to go outside of his schedule that the problems begin. He has told me that he does not feel it when he has to go, or that he doesn't like to use the potty. My question is, do you think the Soiling Solution protocol is appropriate to use for my son? Thank you.

Dr. Collins’ Answer:

This mother provided an excellent background for her child which is very helpful for responding. Basically, the problem here is well pinpointed by the mother when she refers to the effects of disruptions in the family schedule. There are two very important factors that come into play with children who have shown the success that her son has. One is that of relapsing with schedule and activity changes and the other is generalizing to go in foreign or other bathrooms (e.g., school, campgrounds, other homes, etc.).

There are three important chapters in the Clean Kid Manual AFTER the basic chapter of instructions that parents ignore at their peril because these children are so subject to relapses. They deal with Troubleshooting, Relapse Prevention, and the Long Haul.

Scheduling can be very important as our BMs become “entrained” to a particular time of day and if that time to go is upset then the withholding can be triggered in these children. The holding response can become so dominant that it is very, very subject to reoccurring at the drop of a hat. These children can relapse with leaving school for a chaotic summer schedule and then relapse again when switching back to a school schedule. Even Christmas vacation can be a relapse trigger. The Soiling Solutions® (SS) protocol quickly gets these kids back in control on schedule changes and for other changes such that their voiding recognition and a coordinated voiding reflex become more robust and resistant to relapsing. Learning, relearning, and generalizing learning so that BMs can occur anywhere at any time is necessary for these at risk children!

This child is described as “… very strong willed and has displayed some mild control behavior problems.” This is not uncommon!  This is another risk factor for learning and complying with demands. Children are not “blank slates” that we can write on and program with ease!  Nope, there is genetics and maybe he is a “chip off the old block!”  Another possibility is a chicken and egg problem. How much is encopresis or being backed up is making him oppositional or is being oppositional causing the encopresis? It takes the strong support of fellow mama bears on the SS parent’s forum to persist and not feel so isolated. One or more mothers on the forum even have diagnosed ODD children (Oppositional Defiant Disorder) and have been especially helpful to the “newbies.”

I see that you have already ordered the Clean Kid Manual. You will gain new insights and confidence to benefit you both and the whole family.

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An Alabama mother losing hope with a 7-year-old daughter on a maximum dose of Ex-Lax.
August 19, 2011

Question:
My 7-year-old daughter has been taking Senna and Miralax for over six months. We are up to 50 mg of Senna a day. She has never missed a bowel movement during that time, yet, she continues to be compacted regularly. I am losing hope for her condition. What should I do at this point? Thanks

Dr. Collins’ Answer:

Your daughter is at the maximum recommended dosage for Senna for children under age12 years. If she has never missed a BM then it would appear to be doing its job. So is she doing it daily? Is she is doing it on the toilet stool? You appear to indicate that she is still backing up and may be continuing to soil, else why would you be writing to me? I really can’t tell because you do not provide sufficient detail. If her colon is enlarged which sounds likely then it can take a year or two to return to near or functional normal. It may never return to its original size, but it can still become functional with the Soiling Solutions® (SS) treatment. You would have to slowly taper her off of the Senna and Miralax as you do SS at the same time with in its carefully programmed use of suppositories and enemas in a daily treatment hour which assures voiding urge recognition and more effective emptying. All of this occurs with very brief sits and a special sequence of weak and strong “rectal primers.” It is a powerful form of "training" which never "took" along the way and is now needed.

I personally do not like seeing Senna used for longer than one week at a time because she may be developing a tolerance to it.  This possibility is disputed, but I prefer to  be conservative on its usage. Your options are presented in the Clean Kid Manual and you would be supported on the SS Parents Forum which comes with ordering the manual at no additional cost. I call the parents Mama Bears because they are so strong and persevering in treating this problem. All of the "oldbies" have succeeded and like to help the newbies. You will love them and they will give you another missing ingredient, HOPE!

A California couple with a 9-year-old daughter on Miralax for six years, while having two to three good bowel movements a day, but continues to back up and soil. 
August 12, 2011

Question:

My child got very constipated when she was potty training and her father was in the hospital for a terminal illness. That was when she was 2.5 years old.  She is now nine and has been on Miralax for almost 6 years with no progress and periodic cleanouts using Miralax She is using the toilet and having good bowel movements two to three times a day, yet she is backed up and soiling again. She has gone clean for a month but gets backed up again. Will Soiling Solutions still work for her if she has a megacolon? How do you make sure when she goes to the bathroom that everything is moving through?

Dr. Collins’ Answer:

The startup of Encopresis can be due to very benign or very dramatic causes such as you described in your question. What is so sad in your situation is that it did not have to be prolonged for some 6 years! This is not your fault. You have been following the current state-of-the-art pediatric gastroenterology practice ideas with the “top down” approach. If you review some of my earlier answers for this column, you will find that the idea of top down “maintenance therapy” works for remission in only 50 percent of cases, after one year, according to some of the best studies that have been done. I find going beyond one year of offering, essentially, the same treatment with maybe some behavior modification thrown in is not well indicated because of the many physical and emotional consequences that can result, not only for the child, but for the family as a whole.

The use of stool softeners alone like Miralax does not truly stimulate the GI tract like laxatives such as Ex-lax and bisacodyl.  Some PedGIs will recommend the use of a stimulant laxative alone without Miralax and some will prescribe both. A recent study at the University of Virginia that can be seen at www.ucanpooptoo.com has used both. The results of that study are not in as yet — I get periodic personal updates from the chief investigator, but I suspect that it is probably more effective than the use of Miralax alone. There is some controversy with a stimulant laxative that they can cause a “lazy colon”. In my own Soiling Solutions® (SS) program I have scenarios where the use of Ex-lax can be useful to speed treatment or get the child “unstuck” and restrict its use for a one week on and one week off basis. The use of Ex-lax in SS is relatively rare, but it can be a valuable aid.

I’ve described biofeedback in earlier answers (see 3rd Paragraph of my answer for 08/02/2011).  Soiling Solutions® (SS) uses suppositories and enemas (S&E--rectal primers) in a carefully stepped manner in a daily treatment hour which gradually shortens as the control is more and more transferred to the child via a Classical Conditioning process and requires the purchase of the Clean Kid Manual and, ideally, participation in the exclusive SS Parents Forum. The use of S&E is very strongly resisted in today’s medical and general culture which is very unfortunate as it addresses both fear issues (via exposure therapy) and sensory-muscle coordination training simultaneously. Parents who are very ambivalent and fearful themselves are apt to become giant echo chambers for their children, which is precisely the last thing that they need! The SS Parents Forum has been a major breakthrough in providing support for the more nervous and scared parents.

Soiling Solutions® with its use of S&E assures daily more complete BMs which can be better monitored in a daily fashion so that you can make adjustments to the protocol to assure an adequate expectation for her BMs and supplement them with “insurance” S&E or Ex-lax if needed to assure more complete and adequate BMs. This daily monitoring and production of discrete BMs is much preferable to the overuse of X-rays which should be done with a gonadal shield and generally in more sophisticated, specialized children’s settings with lower radiation levels. I hope that your family resolves this nightmare soon. The solutions are available, just not well known or understood! You can help to advocate for a more effective treatment with your doctors and other parents facing this same problem.

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A Michigan mom with a 3-year-old daughter and an alert physician who is recommending suppositories.
August 9, 2011

Question: 

My 3-year-old daughter has a history of constipation and holding stool. She has been on Miralax for two months with continuous holding. She is stuck between not wanting to go in her underwear and not being able to go on the potty. Her physician is now recommending suppositories to regain control. How often and how long should they be given. Thanks for your time.

Dr. Collins’ Answer:

Your daughter’s physician was very alert in noting that two months of the standard pediatric “Maintenance Therapy” was not likely to go anywhere with indications of “holding” behaviors. There are way too many parents who actually get stuck for years where there is not sufficient recognition that the real problem derives from "holding" ... which leads to an enlarged colon ... which leads to a deeply engrained brain-mediated holding response. That is a very bad, and vicious, habit that results in a conflict between holding and voiding which now is recognized as dysnergia by a few leading PedGIs.

The pediatrician suggests the use of suppositories for which you are asking, “How often & how long should they be given?” It really is not that simple as there are different suppositories and enemas (S&E) with different effects that must be applied in a given sequence over defined periods of toilet sits and intervals as set forth in my Clean Kid Manual (CKM). The purpose of my program is to transition the child to going on their own. Just using S&E as daily clean outs will not accomplish that purpose. Also, I have found the exclusive Soiling Solutions Parents Forum to be quite critical for success which requires purchase of the CKM.  However, the basic essentials are set forth in my medical journal article at http://www.encopresis.com/Articles.html. I am very much afraid that this issue is much more complex and persistent than your physician or you realize. Share this note and my article with him/her. I would be happy to talk with him if he calls about a hypothetical case. I can also give him a name and number of a PedGI if he prefers to talk with her. To order the CKM go to www.encopresis.com and check out the store there. My best to you and your daughter.

My child has pee control, but not poo control, that makes no sense to me!
08/05/2011

When questions are not available from parents I will address concerns or issues that I commonly encounter from parents or medical professionals.  I will draw directly from the Clean Kid Manual for my response below.  New answers will go up on Tuesdays and Fridays as I have the time available. Dr C.

Dr. Collins’ Answer:

This is a fairly frequent observation that parents make when there is failed bowel training.  The control of pee and poo would appear to be so similar and a simple matter of when to hold and when to let go at a proper time and place.  So if he can do one control function then he must be able to do the other!  There are several reasons why this discrepancy happens:

1.  Pee is just liquid and evacuation of the bladder is much easier than for a solid which can dry out, harden, block passage or be very painful on passing. 
2.  You have more frequent and intense voiding urge signals from the bladder, 6-10 times a day, and a greater sense of relief upon voiding.  Poo evacuation occurs just 1-2 times a day and demands more of an interruption in activity, especially for boys.  You have more “learning trials” to establish a virtuous habit for pee.
3.  The child is likely to experience a lot more distress from parents for poo accidents as opposed to pee accidents.  Children tend to internalize this and a negative reaction suggesting that they AND poo are bad, period.  That promotes more efforts to hold.
4.  Urgent demands to sit for poo as opposed to pee may elicit more oppositional behaviors from a child, especially boys.  Children are not blank slates that we write on, they come with some hard wiring to challenge and survive in the world.
5.  Holding for poo can result in an enlarged and weakened colon that makes recognition of voiding urges more difficult and weakens the strength of the elimination effort.
6.  If the stool is more raw, liquid, or changed by stool softeners you are much more likely to have “oopsie” squirt or oozing accidents while playing, sneezing, coughing,
laughing, running, farting, etc.  Another physical process is “overflow” which can be continuous with small chunks, peanut butter, or liquid stool.  Poo is so much more complicated than pee!
7.  An escalating, vicious cycle is more likely for poo and the key to reversing it and replacing it with a virtuous cycle commonly remains out of reach because of natural human reactions of thinking that the child’s reactions are willful and that the solutions of sitting and voiding should be natural and easy as it appears to be for them and other children.
8.  You can see from the above points that a conflict can be set up between the holding and the voiding reflex, especially for poo.  This is called dysnergia, it is a very deeply engrained issue.  Special training is required to help resolve this conflict.
9.  Basically an encopretic child has been unintentionally trained to hold poo on the toilet stool and doing a super job of it!  The children, parents, and too many doctors lack insight on this basic outcome.  Reversing that training with biofeedback or the Soiling Solutions® (SS) protocol now has to be employed when ordinary and traditional medical/behavioral approaches have failed.  My medical journal article on SS may be read at www.encopresis.com/Articles.html. 

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Massachusetts mother with a 13-year-old who has been on maintenance therapy for Encopresis forever and no recommended change in approach.
August 2, 2011

Question:

My son has had a problem with bowl movements his whole life; the first several years his PCP just kept saying boys take longer to train. He sees a specialist at Tufts Floating Hospital in Boston and is seen by head gastro doctor. In 2008 he had a flexible sigmoidoscopy and a colonic rectal motility tests and they came back normal. The only medication he has been on is Miralax and most recently Amitiza capsules. Nothing has changed.  My son says he just can't feel his bowel movements. There is always soil (lots of) on his underwear. He has to constantly change his underwear. He wears a pad to catch some, but he is 13-years-old and I just don’t know what to do. His primary just blows it off. And his Gastroenterologist just keeps upping his Amitiza dosage, with no change. He says it must be in his head. What do I do? Any information would be greatly appreciated.

Dr. Collins’ Answer:

I will bet that you have been through many of the questions I raised about Encopresis in my very last answer on July 29.  Basically, your docs have been primarily concerned about preventing medical complications that can result from ongoing fecal incontinence. They appear to have ruled out major likely organic causes for fecal incontinence. For them keeping your son safe involves a simple biomechanical notion of keeping his GI tract active and his stools soft. Maybe on top of that they will emphasize a reward chart system to develop better sitting habits and tolerance of the bathroom to sit and void. The frequent notion is that the colon will “shrink back” to a more normal size and become more functional for recognizing fullness cues and a more powerful contraction to expel stool. The softer the stool the less likelihood of accompanying pain and the more likely a virtuous cycle of elimination will somehow occur.

You have been extraordinarily patient with this the docs and this disorder. It is very hard to deal with such an abhorrent body product. Many pediatricians are reluctant to mention alternatives that may be more “aggressive” which might employ the use of suppositories and enemas (S&E). Parents often look at them with disbelief and negativity should this be mentioned and they may not have the time in an office visit to reassure and explain in any detail about its potential value. Also, the use of S&E are common only in serious cases of blockage in the emergency room or by the GIPed doc. The use of S&E as training agents on a more routine basis with a daily treatment hour in my Soiling Solutions® (SS) approach may well be negatively viewed and not understood because of their training. This is why I wrote the Clean Kid Manual and established a parent’s forum relying on this as a common basis for treatment—preferably with medical availability.

An alternative is the use of biofeedback which comes in two basic forms:  1). The use of manometric (pressure) biofeedback which involves the insertion of a balloon into the rectum where it is slowly inflated to determine how much pressure is required for recognition of filling sensations. This is often an important factor and the child receives sensory training to more quickly recognize the filling sensations. Also, he is encouraged to expel the balloon which is lubricated for easier passage and develop better muscle coordination involving the pelvic floor, the external anal sphincter, and related muscles to become more coordinated and reliable.  2). The other form of biofeedback is the use of ElectroMyoGraphy (EMG, myo = muscle from the Greek) to monitor and train the muscles for proper and successful evacuation maneuvers. 

All of the more direct methods of training above basically address dysnergia which is the lack of coordination between the retention and voiding reflexes which is necessary for adequate voiding. The advantage of SS is that it may be done entirely within the home. Manometric biofeedback must be done in a medical clinic. EMG biofeedback can be done in a private clinic office setting by a physical therapist or psychologist. Biofeedback clinicians may be sought at a major medical center and/or by going to www.bcia.org.

I wish you the best and do help to get information back to your impressive experts. They may be encouraged and actually learn from you. If you can break through to them they often become my best supporters. Parents and my “Mama Bears” have been my best advocates for a more direct approach to this horrible and persistent problem. I will be glad to talk or consult with your docs anytime and if they wish to talk to a fellow PedGI I can give them the name of one who uses my SS protocol and wrote a foreword for my next revision (the fifth) of the Clean Kid Manual to appear sometime this Fall. 

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To call Encopresis a “functional disorder” makes no sense for many parents, please explain!
07/29/2011

When questions are not available from parents I will address concerns or issues that I commonly encounter from parents or medical professionals. I will draw directly from the Clean Kid Manual for my response below. New answers will go up on Tuesdays and Fridays as I have the time available.  Dr C.

Dr. Collins’ Answer:

When the physician rules out a disease basis for fecal incontinence the parents become very confused. The physician just accepts it as a medical condition because it is a physical malfunction. It is just what it is. He/she then becomes concerned with the physical or medical consequences which can result. He/she will focus on avoiding a blockage, a megacolon (enlarged colon), urinary tract infections, skin breakdown, etc. It is anticipated that somehow and at sometime the body will start functioning properly. However, this is rarely regarded as a satisfactory response for such a foul body product and the emotional toll it takes on all concerned with no defined end in sight. We naturally speculate, ask questions, and seek solutions!

“Why doesn’t he feel the accident?” “How come he ignores such a smell when it is so obvious to everyone else?” “Why does he fight me about sitting on the toilet?” “Why is he hiding his soiled clothing?” “I know he knows about bowel movements and he has to take responsibility for it, but he just won’t and completely denies having to go and sit on the toilet stool.” “I see him in the oddest postures and it is clear that he is desperately “holding” and fighting having a bowel movement.” “It is so obvious to me and everyone else that it is easy to sit and go when we feel voiding urges.” “He is very smart, but just does not appear to get it.”  “He is just plain stubborn.”

It is almost as if these just cited instances could be about a messy bedroom and why doesn’t the child keep it clean and orderly?  One thing is certain; we can tolerate messy bedrooms, even wet sheets, but anything involving feces is much more intensely provoking and distressing. The degree of emotional conflict, a contest of wills, is all magnified when it involves this foul, smelly, disease-bearing body product. It is nothing like “Wash your hands.” or, “Brush your teeth.”  or, “Clean your room.” This failure of bowel control has very high stakes for the role of a parent. The whole family is affected. It can contribute to divorce.

I am a doctoral level Clinical Psychologist, not a physician. However, I have published in both the medical and the psychological literature. I have a lot of sympathy for parents, physicians, and psychologists alike who find themselves in a kind of twilight zone.  The field I work in is called Behavioral Medicine. It brings light to this mysterious zone and offers more effective approaches to these frustrating conditions. Encopresis involves a dysfunction at the level of the brain. It has a behavioral and a physical expression. Focusing on the gastrointestinal tract alone is misleading. That is a natural focus, but it is wrong. My research and writing have examined the brain mechanisms involved in bladder and bowel elimination. This brings us to a functional physical account for explaining and solving the problem of encopresis which is set forth in my Clean Kid Manual.

What exactly is Encopresis (ink-col-pree-sis) and Enuresis (in-ure-eesis)?
July 26, 2011

When questions are not available from parents I will address concerns or issues that I commonly encounter from parents or medical professionals. I will draw directly from the Clean Kid Manual for my response below. New answers will go up on Tuesdays and Fridays as I have the time available.  Dr. C.

Dr. Collins’ Answer:

Encopresis is a disorder of bowel control marked by at least once a month soilings for at least three consecutive months in children aged four years and older, per the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV), or the same for six months via the International Classification of Diseases-10th Revision (ICD-10). Insurance companies will require one or the other coding system. In addition, organic factors or a disease basis must be ruled out by a physician. Rule outs occur in only about five percent of cases of soiling. Thus, Encopresis is a functional medical disorder. It affects two to four percent of children. The medical specialist for dealing with encopresis is the Pediatric Gastroenterologist. Referrals to a Pediatric Gastroenterologist should be made, at the latest, by five years of age, if the Encopresis is not resolved.

A condition closely related to Encopresis is Enuresis, which is another eliminative disorder. It is a bladder disorder of daytime wetting (diurnal) or nighttime wetting (nocturnal) in children five years and older. It is also regarded as a functional medical disorder once physical bases are ruled out. It affects about 10-15 percent of children (mostly bedwetting). If day or night wetting is present it should be addressed only after bowel control is achieved.

Functional disorders can frustrate physicians and parents. We are familiar with the disease or medical model which has proved to be very effective in treating all manner of problems by treating a physical cause. When physicians offer a simple biomechanical treatment of oral stool softeners or laxatives to drain the colon it makes physical sense, but if accidents continue or learning to go on the toilet stool fails, everyone will want to look deeper. Assurances that the child will grow out of it will begin to sound empty if fecal accidents persist for a year or longer. Waiting for the "Continence Fairy" is not a viable strategy. This explains why parents often find themselves in a kind of twilight zone debating a psychological or medical basis as an origin for their child’s problem! 

The Clean Kid Manual was the first treatment manual made available directly to parents or physicians for treating Encopresis.  The next edition of the Clean Kid Manual due out in the Fall will have two added chapters to deal with daytime and nighttime Enuresis.

Thirteen year old daughter in Idaho with a long history of Encopresis and Enuresis accompanied by fecal smearing
July 19, 2011

Question:

My daughter was successfully potty trained before the age of 4. When she was 6 her uncle died unexpectedly. Since then she has suffered with Encopresis and Enuresis. She takes medication for ADHD and Depression. She has accidents day and night and often smears feces on the toilet or walls. We have been to a Urologist and there is no physical explanation for it. Does your program cover both Encopresis and Enuresis and does her background sound like your program can help us?

Dr. Collins’ Answer:

Fecal smearing cannot be tolerated anywhere and is often greeted with horror and revulsion which can transfer to the child.  Often it is simply associated with the child’s attempts at promoting a bowel movement by digital stimulation or poor self-cleaning skills. Fecal matter can be difficult to remove. The child may smear it about in trying to wipe it off of their fingers. Typically, only a mother can handle this kind of event, but often with lots of frustration, anger, or depression herself! You have been dealing with this for years. This suggests that the standard pediatric approaches of using stool softeners, laxatives, and behavioral reinforcement charts have failed you. It is a shame that you have not had alternatives until you discovered the Soiling Solutions® (SS) protocol. However, even with SS we have many people who are horrified or very anxious about using suppositories and enemas in a daily treatment program. On balance, after considering months and years of soiling and wetting accidents, many parents come around to using SS which stops soiling in 90 percent of cases within two weeks, even as the daily treatment hour may have to be continued. New SS parents become confident with the help of a common manual and the many helpful parents on the SS forum.

You cite a possible onset of soiling with the death of your daughter’s uncle. Such events can be triggers, but it is difficult to cite the uncle specifically because it could be that the memorial services and your household could have been much disrupted and access to the bathroom very confused. Also, during periods of stress, the whole GI tract tends to freeze and stools can be held and dry out which can escalate into painful bowel movements and more efforts at holding. It just does not take much to trigger Encopresis! Demands to sit and produce bowel movements carry its own problems because voiding urges may not be present and, even if there are, her holding reflex will dominate. The mix of bladder and bowel accidents is fairly common. Both the bladder and bowel signals get confused and the anal and urinary sphincters become uncoordinated in holding and releasing in a timely way which results in accidents. Simply telling or commanding the child to release his stools after he sits does not reach the primitive connection involved. That linkage can only be properly reached by the SS protocol.

The current Clean Kid Manual-IV (fourth revision) does not have chapters specifically addressing bladder accidents, but bowel problems must always be treated first and often the wetting then comes under control. The new CKM-V will come out sometime in the Fall. It will include two additional chapters on daytime and on nighttime bladder accidents. You will have to continue to check the www.encopresis.com store to see when the latest revision becomes available, if you choose to wait. You have to be the judge on waiting or not. The SS parents will help you on the wetting issue if you order the current manual. It may take some time for the child to develop independence from the SS protocol because of the length of time she has been incontinent and the likelihood of an enlarged bowel and the very, very bad habit of holding which has become very automatic and unconscious. 

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A New York mother whose doctor recommended the Soiling Solutions® (SS) protocol, but has questions about starting treatment with the Clean Kid Manual in hand.
July15, 2011

Question:

Our daughter has struggled with constipation since age four months. We have gone the Miralax route, then Kondremul, combined with Ex-lax, and enemas more recently. She has been withholding periodically since age one year. She had been doing fine on the Kondremul for the past few months but about 10 days ago, had a harder BM which must have hurt, and since then, she has refused to poop. We have given her enemas every few days, which she fights tooth and nail and makes her hysterical, making it difficult for us to actually give her the enema. We are concerned about damaging her psyche further by forcing enemas or suppositories, both of which make her miserable. The last time we did enemas several months ago, she want back to pooping on her own, but now, perhaps because she is older, she simply holds the front of her diaper and bends over and tells us she is "squeezing", which I assume means she is holding it in. Our doctor has recommended your approach, but since our little one is not yet toilet trained, we don't know if this is appropriate. If so, do we toiled train for both #1 and #2, or focus on #2? Please advise, we are purchasing your book but not sure if this is the right approach given our daughter's young age and her not-yet-potty trained status (ps, we did buy her a potty together yesterday and she insisted on trying it last night. She actually peed standing next to the potty twice, and wiped herself repeatedly so she has the idea ... she is very articulate and bright!)

Dr. Collins’ Answer:

Even very bright children can have trouble mastering these basic toileting skills. Experts talk a lot about children being ready for toilet training, but this, plus today’s pressures and hard-working parents, has given permission to delay training for too long.  Also, the convenience of diaper cleaning services and disposable diapers/pull ups being made larger and larger adds to delays in training. In fact, we now have a huge problem of diaper or pull up dependence. How convenient! When I toilet trained my cat for the toilet stool I had to remove the litter box and loose rugs, talk about dependence! Paper and diaper manufactures love this and now we have sharp denim pull ups available! They have a bottom line too, profits!  To be fair, they are providing a product which is wanted and needed, but maybe it has gone a bit far?

Training between 18 and 36 months is a good window for training. Pee and poo training at the same time is fine and SS is actually a training program which can be applied when difficulty is encountered. Pee training typically occurs first because there are more natural training trials of 6-10 times a day compared to just one or two trials per day for poo. Your doctor used a perfectly fine top down approach with the use of an emulsified mineral oil (stool softener and lubricant) which has a very tolerable marshmallow taste that children love and he added in an Ex-lax (laxative) kicker. The Kondremul added bulk, mixes in better with the stool than ordinary mineral oil, and lubricates which is good for dried out stools. A laxative like Ex-lax more directly stimulates GI tract contractions (peristalsis) to push the stool along toward the rectum. He recommended SS because it succeeds where the usual most preferred top down methods by physicians and parents fails. He caught on that you had had a sufficient traditional trial and needed a more effective default approach. Too often parents and physicians just hope time will work and an effective intervention is put off. The fact that SS employs suppositories and enemas is often very difficult for today’s physicians and parents to accept because of the high anxiety involved in our culture with this very private sanitary and sexual area of the body.

Physicians are most familiar with the use of suppositories and enemas for blockages and emergency situations.The thought of their use for training is something they resist because of their training. Also, the parents tend to react very negatively and it would take a lot of time to reassure parents and encourage them to be positive and matter of fact in their use for a medical purpose. I have extended the SS protocol down to 30 months for the more calm dispositioned children and, frankly, parents!  You have 120 days from the time of ordering the manual for a refund with the return of the manual for its original purchase price (not including postage and handling for its mailing to you or its return). You will be much encouraged to use the manual if needed by the mothers on the SS parent’s forum.

The unusual case of a 3-year-old Pennsylvania boy who has bowel movements mainly in sleep at night or during naps in the day.
July 12, 2011

Question:

Even though I know my son is young, he primarily has bowel movements during his sleep. This started at a young age and as a baby, I remember his only bowel movements being at 2 AM, 4 AM, 6 AM, during morning nap and then again during afternoon nap. Now at age three he has about 2-3 large and loose bowel movements a day. They typically occur during afternoon nap, possibly while falling asleep at night (sometimes it will occur before he falls asleep) and then one wakes him up for the day. He also had a bug with diarrhea recently that caused him to have 8 bowel movements the first night, 2 during the day and 7 the following night. It just doesn't seem normal to me that he would have this problem. I would think it was related to toilet training but he has consistently had more bowel movements during sleep since the newborn days. The pediatrician describes the problem as odd but not of medical significance. Have you ever encountered a problem like this? Any suggestions? Thanks!

Dr. Collins’ Answer:

This is really quite a rare condition. It has engendered pessimism in some medical quarters, but I see it as fairly reversible. The oddity in this case is that the normal developmental sequence for elimination is bowel-asleep, bowel-awake, bladder-awake, and, finally, bladder-asleep. Thus, this child is going against a normal developmental sequence. I have encountered only three or four such instances over the course of some 30 years.

I did a lot of original research to establish the legitimacy and effectiveness of the bedwetting alarm which is regarded as the most effective treatment intervention available to date for bladder control asleep even over medications. The new Clean Kid Manual-V to be published this Fall, features two extra chapters on bladder control awake and asleep. Your situation is sufficiently rare that I did not consider addressing Encopresis in sleep, but may in a future edition. It would only require an additional paragraph or two to address it.

What is not often understood about sleep is that it is not just going unconscious and awakening later. It actually is a very dynamic state with a lot going on in it. The cases of Encopresis in sleep that I have treated have responded well to the Soiling Solutions® (SS) protocol as it is set forth in the Clean Kid Manual. No, we are not suggesting a bedwetting or bowel alarm in sleep. Rather, we need to shift his natural internal bowel alarm to work when he is awake. Once he learns to respond to it when awake, and toilets properly, the problem will be solved because he will be sufficiently emptied out that he will be disarmed for “going off” in sleep. The SS protocol will teach him the conscious awareness of voiding urges and the necessary emptying muscle coordination skills when awake. It does require the use of suppositories and enemas which you may reject, but the alternative is really much less attractive. Chances are that this will resolve his problem of BMs in sleep. Basically, that basic developmental feature of bowel control while asleep, that he skipped over, is just waiting to be activated! You need not wait for the new manual that will come out in the Fall. I really doubt that you will want to wait that long and the current manual is quite sufficient along with the help of the mothers on the SS parents’ forum.

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Texas mother with a 9-year-old daughter has ordered the Clean Kid Manual and is looking for a childrens’ support group with other children her age.
July 8, 2011

Question:

My 9-year-old daughter suffers from chronic constipation and Encopresis. We have ordered the manual and look forward to using it. We are working with a physician. She is having a difficult time. She is looking for a children's support group in which she could e-mail with someone her age going through the same thing. She has also had kidney reflux and has had bilateral ureteral reimplantation surgery to correct it. Any suggestions would be appreciated. Thanks...

Dr. Collins’ Answer:

The idea of a support group or forum for children comes up periodically, but I have never seen a successful one. There is a lot of isolation, denial, and embarrassment with this disorder; and I think, the children would have difficulty with constructive problem solving dialogs among themselves. Fortunately, our Parents’ Forum now includes about 530 parents, parent-professionals, and professionals who have ordered the Clean Kid Manual and are entitled to registration. The forum was started in 2004 and has been very integral to the success of the Soiling Solutions® protocol. Some remain on for quite some time to help the “newbies” while others move on. While no kid forums have succeeded, several parents will "share" their children with you back channel if you ask and often the children are just very relieved that there are other children their sex and age on the list going through this issue! Frankly, it is often you parents who need the most support and shared insights of the Soiling Solutions® forum beyond the manual itself!

There is a free book on the Internet, entitled “Sneaky Poo”, which I highly recommend. It helps the parents and kids to unite against a common enemy, Sneaky Poo, rather than argue or fight with one another. This reorientation, the manual, the forum, and an “open” physician can make a huge difference for you!

Enjoy the manual and the e-mail traffic from the forum which you should start seeing very soon. Sometimes there are slow downs on the weekends and holidays.  Please read the manual and share it with your daughter so that you have a common base of knowledge before you write out to the forum. Congratulations on taking charge of this problem, you will be very grateful for the changes that you will see much earlier than occurs for any other protocol out there.

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Ontario, Canada mother with a 9-month-old daughter asking if the Soiling Solutions® protocol would be appropriate.
July 5, 2011

Question:

My daughter, who we have been potty training since 4.5 months, has been using the potty for pee and poop since that time without issue. At about nine months, she started eating more solids and became constipated. This led to a difficult poop and she has since been avoiding pooping. When the urge hits her, she grabs at me or tries to get up and off the potty. I spoke to her doctor about it, but she told me that if the stool is still soft, it's not considered constipation and that if it lasted for more than 14 days, she would start her on lactulose. I have a 3 year old who started withholding a few months ago, but we more or less seem to have resolved that issue by being firm and maintaining potty times. As such, I can recognize withholding behaviour and see it in my 9.5 month old. I also know from reading about it from other parents, that it can lead to years of laxative use and Encopresis. I have already given my infant prune juice, acidophilus, and recently, magnesium citrate. Yesterday she had a small poop, but it seemed to just slide out of her. What she is resisting is pushing it out. The only thing that works is using a suppository to stimulate her and then once she pushes it out, she starts pushing with encouragement from me. What I want to know is whether your soiling solutions protocol would be appropriate for my 9-month-old infant.

Follow up from this mother:   Just a quick question. There is much medical opinion that suppositories become habit forming and that eventually, one cannot have a bowel movement without them. Thanks so much.

Dr. Collins’ Answer:

Is it not sad that it takes so little to get a bad habit of “holding” going which can lead to drying out of the stool and result in painful BMs? That can trigger a vicious and escalating cycle that becomes Encopresis, which is defined somewhat arbitrarily at age 4 years if organic factors can be ruled out. Physiological causes are found in only about five percent of the cases of fecal soiling, which has an effect of frustrating everyone because they want a clear cut cause and a pat solution! Your early recognition and take charge mindset for such a young child is wonderful!

Her clutching at you results in the fatal mistake, by many parents, when they comfort and give in to her fears. They are teaching and rewarding her then and there, for not voiding on the potty. They are establishing a bad habit and the vicious cycle to come.  They are mystified when the child continues to hold whenever she is sent to the bathroom or doing so upon doctors’ orders even with the assistance stool softeners or laxatives. In 50 percent or so of cases this can work as the child may have some successful BMs on the potty over the course of a year. The idea is that voiding on the toilet stool becomes a healthy habit and replaces the vicious cycle with a virtuous cycle. It appears to me that you are improving her chances of going on the potty with your conservative use of a suppository primer as needed with the top down primers. Your approach strikes me as appropriate for her age.

The Soiling Solutions® (SS) protocol has been extended down to 2 ½ years when the usual stool softeners, laxatives, sits, and reinforcement protocols are not working. It is designed in such a way that a natural weaning off process takes place until the child’s own urge recognition and voiding coordination takes over from the suppositories and enemas in a regularly scheduled daily treatment hour. At first the “strong” voiding primer is necessary, but then the “weak” primer takes over and, finally, the natural internal primer (your child) takes over. The process is quite demanding, structured, and probably not appropriate for such a young child.

On the question of dependence — why didn’t you ask about forming a dependence on stool softeners and laxatives that bathe the whole GI tract daily and continuously? You say dependence like it is a bad thing! My son has a prosthetic leg, I suppose he could reject it and be “independent”! H-m-m-m? Oh, I am dependent on my glasses and I choose to be dependent on them over corrective surgery, they work just fine, thank you. There is insulin dependent diabetes. Thanks to modern science insulin is a wonderful alternative to blindness, amputations, strokes, and death. But to be fair, I think you are likely avoiding dependence by intervening as early and sensitively as you are before the colon and habit becomes overly strong and established. Soiling Solutions®, in fact, has been successful many times in establishing a virtuous habit without dependence. BUT, if suppositories and enemas were necessary, would that dependence be “bad” by comparison to a lifetime of social isolation and embarrassment?  It does happen, fortunately, very rarely.

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Washington mother of 12-year-old son about to go into Junior High is very concerned about his soiling and wetting.
July 1, 2011

Question:

My son is a 12-year-old boy who is having soiling problems not getting to toilet in time and also pees himself if he laughs too much. About to go to Junior High, so more worrying for both conditions. Had bowel problems from early age, pooping pants etc. Are these two things connected what can we do? Also, he sometimes has constipation and other times loose movements.

Dr. Collins’ Answer:

Yes, the soiling and wetting are likely to be closely connected because of the combined added pressure of a backed up colon and a filling bladder close together in the abdominal region. This can cause recognition confusion for what is going on. The combined pressure creates bladder instability causing many “oopsie” moments with changes that may occur with coughing, sneezing, laughing, postural changes, sports, play, etc. The oopsies can also include bowel squirts, especially if the stool is overly soft from the use of stool softeners commonly used by doctors today. If the stool is hard from drying out because of holding you will still have accidents and occasional toilet clogging stools because the colon has its limits. Yes, there can be an alternation of hard and loose stools. Sometimes the loose stool results from leakage around the backed up stool. Unfortunately, an enlarged colon can take months and even years to recover functionality. But, the Soiling Solutions® (SS) protocol can buy you that time even as he is maintained in an accident-free state as he learns to toilet himself. Both children and parents may appreciate this, but the child can still be resentful and obstinate at toileting demands with the daily SS treatment hour. Frankly, you get the same thing with diabetic children who require insulin shots and who will cheat by sneaking sugary snacks! Hey! They are kids and you are the parents! You will have to be smart and the SS Clean Kid Manual and the SS Parents Forum can help you with that!

You are very right to be concerned as he enters into Junior high where peer groups become more important and offensive body products and smells can result in rejection. I hope that he is somewhat verbal and has some capacity for insight because so many of these children tend to become very defensive and engage in incredible denial so as to preserve their sense of self-worth. The bottom-line is you cannot let this go on indefinitely and should take a more active approach with your child that is more likely to work. Good luck.

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