A Biobehavioral Approach to the Treatment of Functional Encopresis in Children

Abstract Functional encopresis (FE) refers to the repeated passage of feces into inappropriate places at least once per month for at least 3 months. Treatment of FE targets the processes that cause or exacerbate the condition, including reduced colonic motility, constipation, and fecal impaction. The cardinal elements of successful treatment include "demystifying" the elimination process, bowel evacuation, stool softeners, prompts and reinforcement for proper toileting habits, and dietary modifications. Despite misinformation and misinterpretations of encopresis, the assessment and treatment of this condition actually represent one of the more successful achievements of behavior therapy. Keywords: Encopresis, constipation, fecal incontinence. Introduction Functional encopresis (FE) is a common, under-treated and often over-interpreted elimination disorder in children. Although all forms of incontinence require evaluation and treatment, when left untreated FE is more likely than other forms, such as enuresis, to lead to serious and potentially life-threatening medical sequelae and impaired social acceptance, relations, and development. The reasons for the medical sequelae will be summarized briefly below. The primary reason for the social impairment is that soiling evokes more revulsion from peers, parents, and caretakers than other forms of incontinence (and most other behavior problems). As an example, severe corporal punishment for fecal accidents was still recommended by professionals in the late 19th century (Henoch, 1889). Evidence-based practices in the treatment of FE have evolved substantially since then, but the approaches by lay persons (and still some professionals) have not kept pace. Children with FE are still frequently shamed, blamed, and punished for a condition that is most often beyond their control (Christophersen & Friman, 2004; Friman, 2003; Friman & Jones, 1998; Levine, 1982). The definition of FE has remained relatively consistent across versions of the DSM; the DSM-IV (American Psychiatric Association, 1994) lists four criteria for FE: (1) repeated passage of feces into inappropriate places whether involuntary or intentional; (2) at least one such event a month for at least 3 months; (3) chronological age is at least 4 years (or equivalent developmental level); and, 4) the behavior is not due exclusively to the direct physiological effects of a substance or a general medical condition except through a mechanism involving constipation. The DSM-IV indicates that approximately 1% of five-year-olds meet the criteria for encopresis, and males are affected more frequently than females. There are a number of classification schemes for encopresis, but the system most commonly used employs a retentive versus nonretentive dichotomy. Retentive encopresis is defined as fecal soiling with constipation and overflow incontinence, whereas nonretentive encopresis occurs without constipation and overflow incontinence (American Psychiatric Association, 1994). Christophersen and Mortweet (2001) describe constipation as the passage of large or hard stools, often accompanied by complaints of abdominal pain, infrequent bowel movements (fewer than three per week), the presence of abdominal masses upon physical examination, and emotional upset before, during, and after defecation. Constipation is present in approximately 95% of children referred for treatment of encopresis, indicating that retentive encopresis is far more common than the nonretentive classification (Loening-Baucke, 1996). Prevalence Current prevalence rates for the occurrence of encopresis are scarce, and many commonly cited figures are based on studies conducted three or even four decades ago. Recent investigations indicate that the prevalence of encopresis is between 1% to 4% of children, depending on the source and age reported. A Swedish population-based study found that 0. …