Behavioral Medicine Experts Discuss Encopresis Treatments

Encopresis Treatments and Topics | The Soiling Solutions Blog

Soiling Solutions encopresis treatmentsOur blog is a place to read about encopresis treatments, issues, resources, and more. Our site has been so attacked by spammers that we have had to shut down our comments’ feature. Professionals or parents are welcome to submit a blog post by writing to DrC at encopresis.com.

Your specific questions about encopresis are invited for answers to be posted on our Q&A page at http://www.encopresis.com/questions-and-answers/encopresis-questions/. Please check back on some of the past questions and answers.  We will maintain your anonymity without names or very specific locations, but need some basic information about your child’s age, sex, and history that are relevant. Do not be shy, this is a very isolating and vexing chronic disorder that needs to be confronted for your whole family’s well-being! You will be helping other readers who will benefit from your questions and our answers.

Day or night enuresis may well be a complication of encopresis. Your questions about enuresis are also invited.  I was once introduced at the then world’s largest bedwetting clinic at the Royal Children’s Hospital in Melbourne, Australia as “…America’s leading Pyssologist.” I was proud of that title then and now some 37 years later.

Please send in your questions using the form at http://www.encopresis.com/questions-and-answers/send-in-a-question/.

A Survey of Parents On Their Childrens’ Response to Treatment

Here is another way of looking at the results of my Soiling Solutions® protocol. I created a 31 question, mostly qualitative “impressionistic” based survey in early 2014. The survey was sent out via email to all 447 parents that were sent the manual 6 months to 2 years earlier with a 3 week deadline for return. The follow up period being surveyed ranged from 6 months to 2 years. Thirty-eight responses were received yielding a return rate of 8.5%. This is a fairly standard response rate, but I had hoped for better. The results of that survey are presented below.

The age and sex of respondents were as follows:

Male Children:             20

Female Children:        16

Combined Sex:

2.5-4.5 years:                19

5-8 years:                       12

9-11 years of age:          4

Averages for dependent variables with sexes combined (SI=Self-Initiation):

Age                                                                5.27 years

Days Delay in Starting                        13.48

Days to 1st day w/o soiling               10.33

Days to 1st week w/o soiling             16.71

Weeks to 1st Relapse                           10.98

Number of Relapses                               3.90

Weeks to SI with Guidance               10.28

Weeks to Complete SI                         23.44

 

Averages for Girls:

Age                                                                 4.72

Days Delay in Starting                         10.81

Days to 1st day w/o soiling                  8.53

Days to 1st week w/o soiling             21.93

Weeks to 1st Relapse                             9.50

Relapses                                                      3.90

Weeks to SI with Guidance                 8.50

Weeks to Complete SI                         15.33

Averages for Boys:

Age                                                                5.74

Days Delay in Starting                        16.00

Days to 1st day w/o soiling                11.83

Days to 1st week w/o soiling             11.81

Weeks to 1st Relapse                           11.82

Relapses                                                      3.91

Weeks to SI with Guidance               11.92

Weeks to Complete SI                         28.90

 

Look at that difference between boys and girls in reaching self-initiation! Boys can be such stubborn little creatures!  

From the survey look at the time parents delayed actually starting the SS protocol. This reflects a lot of natural fear and anxiety about the aggressive nature of using suppositories and enemas. This is also shared by many medical personnel. It is a world-wide phenomenon.

An inspirational account by a 19-year old woman about Soiling Solutions (SS).

Here is a guest blog by an articulate 19 year old Midwestern young woman whose family confronted her at age 15 years with the Soiling Solutions protocol using suppositories and enemas (S&E) in its daily “Power Hour”. It took a unique, strong, and loving family to do what they had to do! DrC.

I know a lot of parents won’t go the enema and suppository route because of their own inhibitions and concerns about sexual abuse, but I wish more of them could get past that.  When I was thirteen and fourteen and fifteen I was on Miralax twice a day and wearing Goodnites pullups 24/7.  That was 24 hour a day humiliation and degradation and low self-esteem.  I was so confused and scared because I thought this was going to be my life forever.  Miralax would have never taught me to stop holding. It just taught me that I hated my life and never wanted to ever poop again.

When mom and sis put me on SS they handed me a pair of the prettiest green and yellow panties I had ever seen and said I was never wearing pullups again.  They spent most of the morning cleaning me out with soapy enemas and warm water enemas and I fought with all my might and thought they were trying to kill me, but they saved my life and gave me hope.  Mom, I forgive you, and I thank you for saving my life.  I hated enemas and suppositories and still don’t like them because I don’t like anything going in or coming out of my butt but they were never sexual to me.  I didn’t feel I was being molested or abused I just wanted everyone to leave me and my poop alone.

Parents,  taking your child, IF THEY ARE SIMPLY A HOLDER, off Miralax and diapers and spending about one hour a day making them go with an enema or suppository so they could be free from poop for 23 hours is the best gift you could ever give them.  Then there is an end game.  They will get back the ability to go on their own and they won’t need enemas.  You’ve been to so many Drs. and tried so many things.  Keep them clean one hour each day and give them hope.

A Parent-Child Communication Mismatch in Dealing with Encopresis?

It is not uncommon for me to encounter parents at complete loggerheads with their child’s constant soiling. It is so very OBVIOUS: the smell, the visual evidence, his holding behavior, and refusal to sit and use the bathroom. So, it is logical to visually and verbally point this out to the child.  BUT, he does not get it. He denies the evidence of his own senses. Communication fails both parent and child. This is so illogical on his part! So, let’s point this out to him/her over and over again as everyone’s frustrations mount.

When I present the logical process of my Soiling Solutions protocol, which is based on a very simple, elementary conditioning process cited and analyzed in every Psychology 101 textbook, this parent rejects it. It ignores her own analysis of the child’s failure to understand what is so obvious. What is the matter here? Surely the child, her own flesh and blood is not stupid. He is so wonderful and smart in so many other ways. The mother’s observations are correct. If the child obeyed her, his encopresis would cease! Some parents will go on to add a moral dimension or demand that the child be responsible. This only escalates conflict because now you are adding moral outrage.

Well, she might as well be talking to her child in Chinese or German. She is speaking in mature adult language and he listens and cognitively processes at a very different level. His thinking is more impulse and emotionally driven in the immediate NOW. That is his nature. His brain is still developing and his prefrontal cortex is not yet mature enough to harness his basic impulses. He may be thinking such thoughts as “Dun wanna!,” “Ain’t gunna!,” “Leave me alone!” or, “You’re a mean mom!” In fact the human has the longest period of development of any organism on this planet requiring adult guidance for years. We know teen-agers and even young college students act impulsively without the planning and insight that is eventually taken over and guided by the prefrontal cortex.

Soiling Solutions is effective because it is bypasses the higher cognitive and verbal processes. It operates at a more primitive, elementary automatic level of change. Of course, it is fine to use reason and logic for the many years that your child goes to school and learns from you, but keep in mind that toileting is a very primitive behavioral sequence and that can be fostered more directly at an elementary level. Use language to explain what you are doing and to attempt him to get to recognize his bodily sensations and actions, but his insight will follow from the change that you are implementing, not from what you are verbally demanding. For children, insight may follow more from behavioral change and not so much behavior change from the verbal insight that you are trying so hard to convey.

A Psychology 101 Classical Conditioning Explanation for Treating Encopresis.

The Power of Classical Conditioning:

The Soiling Solutions protocol for encopresis is often viewed negatively because of its reliance on suppositories and enemas. In addition, its theoretical rationale is based on a scientific theory which is quite behavioristic. This is often put down as a mechanistic view of we humans that appears to leave out our higher functions and the notion of a soul. Here is the behavioral account for the Soiling Solutions protocol in the simple terminology of Classical Conditioning theory.

Classical Conditioning in the Brain and Below!

The enema is an Unconditioned Stimulus (UCS) and the resulting poop response is an Unconditioned Response (UCR).  You want to eventually get to a Conditioned Response (CR) to the time of day and stimuli associated with recognizing one’s own weak voiding urges (CS complex).  All of this is basic Psych 101 and the abbreviations here are very standard. This is spelled out in my Chapter one of the Clean Kid Manual which can be read at http://www.encopresis.com/encopresis-manual/ in a more persuasive way, I hope.  Needless to say learning theory is not a popular part of Psychology, but it is very basic and important.  In many respects Classical Conditioning is a basic component of cognitive-behavioral approaches, but at a very elementary and powerful level. The basic learned connection is an S-S (stimulus-stimulus) linkage which takes place in the brain and is physically verifiable. It is something real that works and frees the child and parents to be more fully human and engaged in the rest of life.

A Leading Specialist for an Internationally Recognized Bowel Management Program Is Moving

Marc Levitt, MD, director of the Colorectal Center at the Cincinnati Children’s Hospital in Ohio has led a remarkable monthly, week-long outpatient bowel management program that has gained international recognition. Typically bowel management programs dealing with children are operated by Pediatric Gastroenterologists in the Department of Gastroenterology. Dr. Levitt was disappointed in seeing his surgical corrections for children not responding to the usual gastroenterological approaches which led to his program that came to include very difficult cases of encopresis. He termed these cases pseudo-obstruction. They are functional disorders not requiring surgery.  Nevertheless, the parents felt very reassured by his assurances and the success of his bowel management program. I have referred some of my Soiling Solutions parents on to him.  I do not know what will be left of his program at the Cincinnati Children’s hospital. He will settle into his new position at Nationwide Children’s Hospital (NCH) in Columbus, Ohio sometime this coming spring.  Here is the formal announcement of his move by NCH:

A New Bowel Management Program?

We are extremely pleased to announce the recruitment of Dr. Marc Levitt to the Department of Pediatric Surgery at Nationwide Children’s Hospital. Dr. Levitt is a world-renowned expert in the care of children with imperforate anus, cloacal anomalies, Hirschsprung’s Disease and other complex colorectal abnormalities. Dr. Levitt joins us from Cincinnati Children’s Hospital where he was Director of the Colorectal Center for Children, Program Director of the Pediatric Colorectal Surgery fellowship, and Associate Director of the Pediatric Surgery Training Program.  Dr. Levitt’s expertise in the care of children with complex gastrointestinal anomalies attracts patients from countries all over the world. Dr. Levitt will come to NCH as the Surgical Director of the Center for Colorectal and Pelvic Reconstruction, and as Director of the newly established Pediatric Colorectal fellowship. Dr. Carlo Di Lorenzo, Chief of Pediatric Gastroenterology and Robert and Edgar Wolfe Endowed Chair in Pediatric Gastroenterology at NCH, a world renowned expert in gastrointestinal motility, will be the Medical Director of the Center. Together with the international expertise of Dr. Steve Teich and Dr. Hayat Mousa in the surgical and medical management of intestinal dysmotility, and the well known bowel management program that Dr. Levitt provides for patients with fecal incontinence, we expect that Dr. Levitt’s recruitment will allow NCH to become the most renowned center for pediatric gastrointestinal disease in the world.  Dr. Levitt will also be working closely with Dr. Rama Jayanthi, Chief of Pediatric Urology, who will address the urological needs of the complex patients cared for in the Center, and with Drs. Kate Deans and Peter Minneci, Co-Directors of the Center for Surgical Outcomes Research, to critically assess the clinical outcomes of the patients cared for in the Center. Dr. Levitt’s academic appointment will be in the Department of Surgery at The Ohio State University, which is chaired by Dr. Robert Higgins.

Dr. Levitt received his undergraduate degree from the University of Pennsylvania and his medical degree from the Albert Einstein College of Medicine. He completed his general surgery residency at Mount Sinai Medical Center, a fellowship in Pediatric Colorectal Surgery at Long Island Jewish Medical Center, and a Pediatric Surgery fellowship at Children’s Hospital of Buffalo. After completing his training. Dr. Levitt was on the faculty at Children’s Hospital of Buffalo for two years, at Schneider Children’s Hospital, North Shore-Ling Island Jewish Medical Center for three years, and at Cincinnati Children’s Hospital for eight years.

Dr. Levitt has published over 120 manuscripts and 60 book chapters, and has delivered over 300 national/international and 100 local/regional presentations of his work. He has been an invited visiting professor all over the world. Dr. Levitt has trained numerous clinical fellows, research fellows and students in his career. He has directed numerous colorectal training courses attended by established surgeons and surgical trainees from all over the world. He dedicates much of his free time to mission trips around the world where he trains surgeons in his complex surgical techniques.

While it is clear from his academic accomplishments that Dr. Levitt is a superb surgeon with tremendous expertise, even more importantly, it is clear that Dr. Levitt is a superb human being. He is unwaveringly committed to the care of children with colorectal problems. He is tireless in his endeavors to provide the best possible care for these patients. He brings to Nationwide a wealth of ideas for ways to improve the care of these complex patients.

Very Early Signs of the Twilight Zone for Holding in Children: To Treat or Not to Treat?

The Twilight Zone in Understanding the Early Onset of Encopresis and “To Treat or Not to Treat”?

I have noted in the last two blog entries that the most common onset of encopresis occurs during toilet training and upon entry to school. Somewhat arbitrarily, encopresis can only be diagnosed at 4 years of age according to diagnostic criteria. However, there are a number of children that begin holding much earlier than for any of these occasions. This can often be associated with hard and overly large stools that are difficult or painful to pass, but not always. Some kids just find bowel elimination to be resisted for whatever reasons which may remain forever in the twilight zone of understanding. The simple behavioral fact is that it happens and is not to be denied because reality is reality.  Now humans, being humans, will start up offering all manner of possible reasons. I do not expect to authoritatively pronounce explanations here.  All I can do is offer some considerations for parents and physicians in addressing this problem.

Some Considerations for To Treat or Not to Treat If You Find Yourself in the Twilight Zone:

  1. Will this lead to an enlarged colon compromising future efforts at toilet training? Yes, it can enlarge the colon. The longer it remains enlarged, the less sensitive and weaker the colon will become. It will sabotage toilet training, especially for poo!
  2. Will this deepen a holding habit and lead to dysnergia? Dysnergia is a condition of confusion in coordinating voiding urge signals and the coordination of the muscles themselves that permit successful elimination. Yes, this is very likely and the longer it exists the more difficult it will be to reverse holding.
  3. Do you intervene with stool softeners to actually promote stool leakage to avoid dysnergia? Yes, it is worth a trial if it is effective until toilet training time. Unfortunately there are children who can successfully hold even liquefied stool. Also, constant leakage can promote rashes and infections which really is to be avoided because more pain will reinforce the holding.
  4. Can suppositories and enemas be employed in very difficult cases on a more routine, even daily basis to avoid the aforesaid complications or produce even newer ones? I think, yes. Many Soiling Solutions parents wish they had intervened more effectively much earlier with the signs of holding.
  5. The physician and parent will have to collaborate on the best path forward, To Treat or Not to Treat?


Readers are invited to offer their own comments:

 

Toilet Training Conflict and the Onset of Encopresis

The most common onset of encopresis occurs during toilet training. Going to school is the second most common onset which is covered in the next blog below. Toilet training conflict involves a major initial confrontation between the parent and child. This can trigger a contest of wills. The parent is making a demand for the child to switch out of the convenience of diapers to go to the bathroom to pee and poo. Pee is much less of a problem because the signal urges are so recognizable, followed by quick and easy voiding, immediate relief, and it requires much less in the way of a cleanup. Pee is liquid and flows easily, while  poo is more or less a solid. Poo has an immediate foul odor and it is clear that people wrinkle their noises and display disgust. Elimination of poo is literally more difficult and requires more coordination of the muscles to facilitate its expulsion.  Also its passage may encounter more or less resistance depending on how dried, hard, and large the stool mass may be.  If the child is upset with the interruption of his activity to go to the bathroom, the relevant muscles of the pelvic floor and sphincter are less able to relax and to facilitate passage.

Toilet training typically comes at a time when the child is becoming much more autonomous in his or her mobility.  They develop their own opinions and notions about what they want to do or not do. Parental demands to go to bed or to toilet are much more interruptive of their activities and likely to trigger intense resistance and even resentment. Both sides form opinions and theories about the other which can enhance conflict. Judgments of good, bad, or evil quickly become organizing themes. This  hardens conflicts which can escalate. A child’s job is to challenge and test; the parent’s job is to maintain calm, love, provide authority, and set limits in the child’s own best long term interests. This is another source of conflict, immediate versus long term interests. The human organism requires the longest period of education and supervision than any other living organism. We possess lower brain systems deep inside the brain and more recently evolved higher brain systems that have to be developed by parents and the culture.

The Presence of Peeing and Pooping Problems in Our Schools.

Holding behavior for pee and poo is likely for our children in school. This causes “border conflicts” between the colon and the bladder in the lower abdominal area creating confusion and instability of both organs. This can increase the risk for both bladder and bowel accidents. The second most common onset of encopresis is associated with going to school. Why is this? Moving about in the classroom may be seen as disruptive and there is a tendency by teachers at teaching moments to ask the child to “hold”  for a bathroom visit for just a bit, which then is forgotten and the child may experience less urgency. Even a teacher’s unguarded, automatic look of disapproval or irritation may intimidate the child to not annoy the teacher.  Holding is even more likely in the school lavatories because of noises, the awareness of the presence of others, filth, smells, farting sound, lack of toilet paper, etc. for what is regarded as a very private act.  Toilet paper may be lacking. The child may have concerns about “germs” because of home teachings.  Our culture promotes all manner of negative associations and concerns with what is often viewed as this private, sexual, dirty area of our bodies.

School can be stressful and exciting for a child which sets up a much less active GI tract during the majority of the school day, a sympathetic nervous system dominant state. This promotes a drying out of stool. Also, the child is likely to drink much less during the day causing more drying out the stool and helping the child to avoid having to pee. However, as the end of the school day approaches the child is much more likely to relax anticipating their return home.  This can cause a “rebound,” a para-sympathetic dominate effect, which promotes a much more active GI tract and the likelihood of accidents. If he/she has been avoiding drinking then they will drink more after school and be more subject to bladder accidents for that reason as well.

An important and highly readable book, It’s No Accident: Breakthrough Solutions to Your Child’s Wetting, Constipation, and UTIs, and Other Potty Problems was published in 2012 by a Pediatric Urologist from the Wake Forest Medical School. The author is Steve J. Hodges, MD with Suzanne Schlossberg.  Be sure to have a look at www.itsnoaccident.net. Dr. Hodges has some excellent ideas for prevention and treatment. He notes the use of enemas as a legitimate option for a sustained period of time which is one of the features of the Soiling Solutions protocol set forth in detail in my Clean Kid manual.

A Psychologist Trains the Brain to Treat Encopresis

Views from Above and Below:

A psychologist may diagnose and treat encopresis under their scope of practice.  A physician should rule out the presence of physical causes for the presence of fecal soiling in children over age four years. The physician may proceed with treatment typically using top down oral medications on a maintenance basis following a clean out of a colon that is overfilled with feces. Most psychologists may follow a similar course and work on compliance and emotional issues.

The Much Neglected Role of Specifically Training and Connecting the Voiding Response with Toilet Sits:

My approach is quite unique and not understood by many physicians and psychologists because I use a learning theory-based approach based on the special properties of bottom up medications. The reasons are really very simple:

  1. Oral medications have a delayed effect of 6-10 hours in promoting evacuation at the end of the very long gastroenterological (GI) tract. Bottom medications have a much more pronounced and immediate effect in promoting voiding urges recognition and evacuation by the child.
  2. This allows a much superior pairing or connection of urges with the bathroom, sitting, and successfully having a bowel movement. This is severely compromised for the oral medications that may promote many more confusing and vague sensations over the course of their action. In fact, it is likely that such confused stimuli and holding tendencies will promote a reinforcement of holding rather than releasing when sitting in the bathroom!
  3. Biomechanically the use of bottom medications are more likely to adequately empty the colon sufficiently each day that the child is safe form soiling for the next 24 hours and allow it to return to a more normal condition and size.  This should enable better urge recognition over time by the child along with the reinforcement of the stimulus-response connection.
  4. The principles here are based on the work of a Nobel Prize winner (1904), Ivan Pavlov, MD, who studied the conditioning of salivation in dogs at the top of the GI tract. I have basically done the same thing at the bottom of the GI tract.
  5. Repeated case studies have demonstrated the power of my approach in a subject as his own control design.
  6. A treatment comparisons study demonstrating the power of Pavlovian conditioning for a related disorder, bedwetting or nocturnal enuresis, was performed and published by myself in my doctoral dissertation at Indiana University’s now renamed Department of Psychological and Brain Sciences. It was later published in a professional journal and widely reported in over 100 citations in other journal articles and book chapters.

 The Role of the Brain:

A medical specialty emphasis on a given organ system often leads to a too narrow focus on that lower system. I have attempted to bring attention back to the integration of the GI tract with the highest organ, the brain.