IACAPAP Textbook of Child and Adolescent Mental Health

DEVELOPMENTAL DISORDERS

Chapter

C.5

ENCOPRESIS
Alexander von Gontard

Alexander von Gontard
Department of child andadolescent psychiatry, Saarland
University Hospital, Homburg,
Germany
Conflict of interest: none
disclosedThis publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: von Gontard A. Encopresis. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva:
International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

Encopresis

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IACAPAP Textbook of Child and Adolescent Mental HealthEncopresis (or fecal incontinence) is a disorder which affects children worldwide. It is even more stigmatized than enuresis and urinary incontinence
and is associated with high levels of distress for both children and parents.
Also, the rate of comorbid emotional disorders is higher, affecting 30%-50% of allchildren with encopresis (von Gontard et al, 2011).
Two major forms of encopresis can be differentiated: encopresis with andwithout constipation. The specific differentiation into these two subtypes is ofutmost importance as they differ according to pathophysiology, clinical features
and, especially, treatment (i.e., the former does not respond to laxatives, whilein the latter they are essential in treatment). The aim of this chapter is to givean overview and practical approaches to assessment and treatment of these two
subtypes of encopresis.

DEFINITION AND CLASSIFICATION
According to ICD-10 (World Health Organization, WHO, 2008) and
DSM-IV-TR (American Psychiatric Association, APA, 2000), encopresis is definedas both voluntary and involuntary passage of feces in inappropriate places in achild aged four years or older, after organic causes have been ruled out. Despite
major similarities between the two systems, they differ regarding essential points,
especially the definition of subtypes. In ICD-10, one episode per month for atleast three months is needed. ICD-10 does not define subtypes nor differentiate
clearly between encopresis with and without constipation. The duration requiredfor diagnosis in DSM-IV-TR (2000) is the same but it distinguishes between
encopresis with and without constipation.
Table C.5.1
Rome-III diagnostic criteria for functional constipationand non-retentive stool incontinence (Rasquin et al, 2006)
Functional constipation*
Must include two or more of the following in a child with a developmental age of atleast four years with insufficient criteria for diagnosis of irritable bowel syndrome:•
Two or fewer defecations in the toilet per week•
At least one episode of fecal incontinence per week•
History of retentive posturing or excessive volitional stool retention•
History of painful and hard bowel movements•
Presence of a large fecal mass in the rectum•
History of large diameter stools that may obstruct the toilet.
* Criteria must be fulfilled at least once per week for at least two months
Non-retentive fecal incontinence*
Must include all of the following in a child with a developmental age at least four
years:•
Defecation into places inappropriate to the social context at least once permonth•
No evidence of an inflammatory, anatomic, metabolic, or neoplastic processthat explains the subjects symptoms•
No evidence of fecal retention* Criteria must be fulfilled for at least two months

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IACAPAP Textbook of Child and Adolescent Mental Health

Based on current research and validation studies, the most precise taxonomy
was proposed by pediatric gastroenterologists in their Rome-III classification forfunctional disorders of the gastrointestinal tract (Table C.5.1) (Rasquin et al, 2006).
The first difference is that the neutral term of fecal incontinence was chosen insteadof encopresis. This means, that fecal incontinence and encopresis can be used assynonyms (as in this chapter). The second change is that constipation was definedas the main disorder that can − but does not necessarily have to − be associatedwith soiling. Constipation is, in fact, more common than encopresis: many
constipated children do not soil. The main symptoms of functional constipation
can be seen in Table C.5.1. The definition of constipation cannot be based ona low defecation frequency on the toilet alone: some children pass stools every
day but still retain fecal masses in the rectum and colon. Therefore, additional
clinical signs and symptoms are needed and these are listed explicitly in the RomeIII criteria. The authors chose a shorter duration − two months − to encourage
early treatment and to avoid chronification. Two symptoms must be present: alow defecation frequency; soiling; holding maneuvers; painful, hardened stool; andlarge fecal masses.
For encopresis without constipation, the neutral term of non-retentive fecal
incontinence was suggested. The etiology of this subtype is not known and muchless research has been generated for this disorder than for constipation (Bongers etal, 2007). Except for a shorter duration of two months, the criteria are similar to
those of DSM-IV.

EPIDEMIOLOGY
Encopresis is a common disorder affecting 1% to 3% of children older thanfour years (the definitional age). Three different trajectories can be defined (Heronet al, 2008):•••

Children with chronic encopresis over many years
Those with relapses, andA group with a tendency to remit spontaneously.

In a Dutch study, 4.1 % of 5-6 year olds and 1.6 % of 11-12 year olds wereaffected (van der Wal et al., 2005). Prevalence depends on the definition used; forexample, 5.4 % of 7-year old children soiled, but only 1.4 % once or more per
week (Joinson et al, 2006). Encopresis can persist into adolescence and even young
adulthood. Without constipation (i.e., non-retentive fecal incontinence), 49% ofchildren soiled at the age of 12 years, and 15% at 18 years in a long-term follow
up (Bongers et al, 2007). The prognosis of constipation is less favorable: only
80 % had a good outcome by the age of 16 years, and 75% to 80% at 16-27 years(Bongers et al, 2010).
Three to four times more boys are affected by encopresis than girls (Bellman,
1966). Encopresis occurs almost always during the day (Bellman, 1966). Nocturnal
encopresis is more often associated with organic causes and requires a more detailed
somatic assessment.
Most children from the age of four years onwards have one bowel movementa day – with great individual variability (Bloom et al, 1993). Chronic constipation
is a more common disorder than encopresis. According to a large meta-analysis,
the median prevalence was 9% world-wide with different definitions used (vanEncopresis

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IACAPAP Textbook of Child and Adolescent Mental Healthden Berg et al, 2006). This meta-analysis included studies from countries such as
Italy, US, Hong Kong, Japan, Finland, Turkey, Brazil, Saudi Arabia, among others.

CLINICAL SIGNS AND SYMPTOMSAs the differentiation of the two subtypes – constipation and non-retentive
fecal incontinence − is decisive for treatment, it is important to know the basic
signs and symptoms of each. Based on the research of Benninga et al (1994; 2004),
as well as others, the main differences between the subtypes are shown in Table
C.5.2.
Children with encopresis with constipation (or functional constipation) havea reduced number of bowel movements with large stools of altered consistency (toosoft or too hard). They often experience pain during defecation. Abdominal pain
and reduced appetite are typical. The colon transit time is increased, abdominal
and rectal masses are palpable. In sonography, the rectal diameter is increased (> 25mm). Often, daytime urinary incontinence and even enuresis co-exists. Additionalemotional and behavioral disorders are found in 30%-50% of them and, finally,
laxative therapy is helpful.
Children with encopresis without constipation (non-retentive fecal
incontinence) do not have many of these symptoms. They have daily bowel
movements of normal size and consistency. Pain is not frequent and appetite isTable C.5.2 Differences between encopresis with constipationand non-retentive fecal incontinence
Encopresis withconstipation

Non-retentive fecal
incontinence

SeldomDaily

Large amounts of stools

Yes

No

Normal stools (consistency)

One half

Nearly all

Pain during defecation

One half

SeldomAbdominal pain

Often

SeldomAppetite

ReducedGood

Colon transit timeLong

NormalPalpable abdominal mass

Often

None

Palpable rectal mass

Often

Never

Rectal diameter (sonography)

Increased

NormalDaytime urinary incontinence

One tenth

SeldomNocturnal enuresis

One third

Tenth

Comorbidity with behavioral
and emotional disorders

30%-50%30%-50%Laxative therapy

HelpfulNot helpful, evenworsening

Bowel movements

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4IACAPAP Textbook of Child and Adolescent Mental Healthgood. Colon transit time is normal and no stool masses can be palpated. Enuresis
and urinary incontinence are less common, while comorbidity with psychologicaldisturbances is similar (30%-50%). Finally, laxatives have no effect – can evenworsen the soiling.

ETIOLOGY
Fecal continence is achieved following night-time and daytime urinary
continence (Largo et al, 1978; 1996). Early toilet training can lead to early fecal
continence in infancy and toddlerhood but has no influence on the development of
encopresis at the age of 4 years. Encopresis can be preceded by delayed development
and difficult temperament in the child, as well as maternal depression and anxiety(Joinson et al, 2008).
Functional constipation
Genetic factors do play a role in constipation but less so in encopresis. The
concordance rate for constipation for monozygotic twins is 70%, for dizygotic
twins 18%. The risk of occurrence is 26% if one parent is affected, 46% if bothparents, 40% if father, and 19% if mother is affected (Bakwin & Davidson, 1971).
Functional constipation often develops after an acute constipation, which
affects 16%-22% of young children. This can be triggered by a wide variety ofpsychological factors such as stressful life events, losses, family conflict, as well as
somatic factors such as anal fissures, changes of diet, intensive toilet training andmedication (Cox et al, 1998). Irrespective of the initial triggers, a sequence ofchronic stool retention can follow. Acute constipation causes painful defecation
and avoidance of defecation, inducing a paradoxical contraction of the external
anal sphincter, which becomes habitual. Avoidance of bowel movements leads toaccumulation of fecal material in the rectum and colon. Transit times are increased,
peristalsis and sensation are decreased. Fluid withdrawal leads to large, hard fecal
masses and a megacolon. Encopresis occurs because of interference of these masses
with rectal function and by fresh stools bypassing the hard fecal masses.
Non-retentive fecal incontinence
In contrast to the clear model of functional constipation, the etiology of
non-retentive fecal incontinence is not known (Bongers et al, 2007). It cannot
be caused by psychological factors alone, as the comorbidity rate of both typesof encopresis is the similar: 30%-50% of cases (Benninga et al, 1994; 2004; von
Gontard et al, 2011).

COMORBIDITY
Overall, 30-50% of all children with encopresis have a comorbid emotionalor behavioral disorder. This means, that three to five times more children withencopresis have additional disturbances in comparison to non-soiling children.
In a large population-based study of children aged 7½ years, children withencopresis had significantly increased rates of separation anxiety (4.3%), specificphobias (4.3%), generalized anxiety (3.4%), ADHD (9.2%) and oppositional
defiant disorder (11.9%) (Joinson et al, 2006). In other words, children with fecal
incontinence show a heterogeneous pattern of both internalizing and externalizing
disorder comorbidity. Regarding subtype, encopretic children with constipation

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5IACAPAP Textbook of Child and Adolescent Mental Health

Table C.5.3

Standard and extended assessment of encopresis

Standard assessment (sufficient for most cases)
•
•
•
•
•

History
Questionnaires and scales
Physical examination
Sonography (not in all centers)
Screening for behavioral disorders or full child psychiatric assessment

Extended assessment (only if indicated)
•
•

•
•

Stool bacteriology
Radiology:− Plain abdominal x-ray− Colon contrast X-ray− MRI of colon
Manometry
Endoscopy and biopsy

have similar rates of behavioral scores in the clinical range as children without
constipation (Benninga et al, 1994; 2004). In other words, they cannot be
differentiated according to the behavioral comorbidity.

DIAGNOSISThe assessment of children with encopresis should be as non-invasive as
possible, and should always include parents or other caregivers. For most children,a basic evaluation that can be conducted in many primary care settings is sufficient(Table C.5.3).
The history is the most important aspect of assessment. If conducted
correctly and empathically, the most relevant information will be gathered throughthe history. It is worthwhile to take enough time during the initial consultation.
Useful questions for a detailed history can be found in Appendix C.5.1.
Questionnaires can be a useful and time-saving procedure to gain
information and to check if the information obtained through history is complete.
A short questionnaire is shown in Appendix C.5.2.
A very useful chart is the Bristol Stool Chart. Seven types of stool forms
are depicted ranging from “separate hard lumps, like nuts (hard to pass)” (type1) to “watery, no solid pieces, entirely liquid” (type 7). The scale enables parents
and children to identify the predominant type of stool easily and without lengthy
descriptions. The course of treatment can also be monitored using this scale.
Each child should have a physical examination. Both a general pediatric anda neurological examination are recommended. The perianal and perigenital areas
should be inspected. Spine, reflex differences and asymmetries of buttocks should
be noted. A rectal examination should be performed at least once. If sonography isavailable, this can replace the rectal exam if no organic form or fecal incontinence
is suspected.

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IACAPAP Textbook of Child and Adolescent Mental HealthIf available, sonography of abdomen, kidneys, bladder and retrovesicalregion is helpful. The most important finding is an enlarged rectal diameter of>25-30 mm in children with constipation (Joensson et al, 2008). In these cases, a
rectal examination can be avoided. If sonography is not possible, a standard rectal
exam should be performed and rectal masses can be palpated.
Due to the high comorbidity rate, a child psychiatric assessment isrecommended in child psychiatric settings. In other settings, screening withvalidated questionnaires (such as the Child Behavior Checklist; Achenbach, 1991)
is recommended. If scores are in the clinical range, further assessment or childpsychiatric referral is recommended (von Gontard et al, 2011).
All other examinations are not routinely indicated – only if an organic typeof fecal incontinence is suspected. It is important to avoid unnecessary and invasive
investigations. Further details regarding assessment can be found in von Gontard
and Neveus (2006).
Differential diagnosis
Somatic causes are present in 5% of children with chronic constipation andmust be ruled out. These include anatomic causes such as anal fissures, abscesses,
skin tags, dermatitis, anal stenosis and other ano-rectal malformations. Metabolicand endocrine causes include cystic fibrosis, celiac disease, cow milk intolerance/allergy, diabetes mellitus and hypothyroidism. Neurological causes include cerebral
palsy, spina bifida and myelomeningocele. Constipation can also be caused byvarious drugs (von Gontard and Neveus, 2006).
The most important differential diagnosis is Hirschsprung’s disease, which
affects 1:5000 infants and is an intrinsic neuromuscular disease of the gastrointestinal
tract characterized by aganglionosis. Symptoms begin in the neonatal period withvomiting, abdominal distension, and food refusal. Older children can have small
caliber stools, while soiling is a rare symptom. Most cases (80%) are diagnosed by
the age of 4 years (Felt et al, 1999).
Organic causes in non-retentive fecal incontinence are much less frequentaffecting a maximum of 1% of children. The most important are infectious
diarrhea, neurological conditions such as spina bifida occulta and postoperative
residual symptoms.

TREATMENT
Following assessment, children and parents are given detailed informationon the subtype of encopresis (psychoeducation). As in the treatment of enuresis,
unspecific factors such as enhancing motivation and building a good therapeutic
relationship are helpful. Feelings of guilt, dysfunctional parental attributions (“mychild is doing this on purpose”) and frustration can be verbalized. Ineffective
parental interventions such as punishment or non-indicated medication can be
discussed with parents. If the child’s food intake is restricted to low fiber foods,a change in the child’s diet can be useful. Also, the amount of fluids should be
increased, as many children do not drink enough during the day.
Toilet training
A baseline period with observation and recording is not necessary. Instead,toilet training is initiated right from the start. This training is indicated for both

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IACAPAP Textbook of Child and Adolescent Mental Healthtypes of encopresis. Children are asked to sit on the toilet three times a day, after
mealtimes. This time is especially useful as the postprandial defecation reflexes arethen most active. Children are asked to sit on the toilet five to ten minutes in arelaxed way, for this, it is important that their feet touch the floor. Otherwise alittle foot-stool should be provided. These toilet sessions should be experienced ina positive way: children are allowed to read comics, books, play with computersor cell phones, draw pictures, etc. They do are not expected to pass urine or stools
every time. These toilet sessions are documented in a chart as depicted in Appendix
C.5.3. If necessary, the co-operation of the child can be enhanced positively by asimple token system with small rewards. All criticism or punishment should be
avoided.
Laxatives
In non-retentive fecal incontinence, this toilet training is the main aspect oftreatment. Laxatives are not indicated. In children with constipation, toilet training
is combined with laxatives: first disimpaction, then maintenance treatment.
Disimpaction is necessary to evacuate fecal masses at the beginning oftreatment. This can be performed rectally or orally. In rectal disimpaction, enemas
are applied. The most widely used and recommended are enemas containing
phosphates such as sodium hydrogen phosphate and sodium monohydrogen
phosphate. Recommended doses are 30ml/10kg of bodyweight or half an enema
for pre-school children, ¾ to one enema in school children. Often, these have to berepeated several times. An alternative is oral disimpaction with polyethylenglykol(PEG; macrogol). Large doses of up to 1.5g/kg body weight per day are given.
Sufficient oral fluids are required for this osmotic laxative to be effective.
Once large stool masses have been passed, a lower maintenance dose should
be given. Through these procedures success is achieved in 80% of children withrectal and 68% with oral disimpaction, both leading to a normalization of colontransit times (Bekkali et al, 2009).
Maintenance treatment
After successful disimpaction, a long-term maintenance treatment over aminimum of six months to two years should follow to avoid re-accumulation ofstool masses (Felt et al, 1999). In addition to toilet training three times a day
after mealtimes, oral laxatives are given. The standard and most effective laxative ispolyethylglykol (PEG; macrogol), a long, linear polymer that binds water (Candy& Belsey, 2009; Pijpers et al, 2009). Side effects such as abdominal pain are rare.
The initial dose is 0.4g/kg bodyweight per day in two doses. If stools are too hard,
the dose is increased, if too soft, reduced. The therapeutic range varies from 0.2g/
kg to 1.4g/kg bodyweight per day (Nurko et al, 2008). Lactulose, a disaccharide, isless effective and has more side effects. The dosage of liquid lactulose ranges from
1ml/kg to 3ml/kg bodyweight per day in one to three doses.
If comorbid emotional and behavioral disorders are present, these need to
be treated separately. Untreated comorbid disorders will reduce adherence andcompliance and outcome of encopresis treatment will not be optimal.

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8IACAPAP Textbook of Child and Adolescent Mental Health

COURSE AND OUTCOME
The untreated long-term course of both types of encopresis is not favorable.
Constipation and non-retentive fecal incontinence can persist into adolescenceand even young adulthood (see epidemiology). Therefore, encopresis needs tobe treated actively and patients should be seen at regular intervals. In case of
constipation, laxatives should be given for long enough; two years or longer insome children.

REFERENCES
Achenbach TM (1991). Manual for the child behavior checklist/4-18 and 1991 profile. Burlington: University ofVermont.
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, 4th edition, text revision.
Washington, DC: American Psychiatric Association.
Bakwin H, Davidson MD (1971). Constipation in twins.
American Journal of Disease in Children, 121:179-181.
Bekkali N, van den Berg M, Dijkgraaf MGW et al (2009). Rectal
fecal impaction treatment in childhood constipation:enemas versus high doses oral PEG. Pediatrics,
124:e1108-e1115.
Bellman M (1966). Studies on encopresis. Acta Paediatrica
Scandinavica, 170 (sup):1-151.
Bennigna MA, Buller HA, Heymans HS et al (1994). Is
encopresis always the result of constipation? Archives of
Disease in Childhood, 71:186–193.
Bennigna MA, Voskuijl WP, Akkerhuis GW et al (2004).
Colonic transit times and behaviour profiles inchildren with defecation disorders. Archives of Disease
in Childhood, 89:13-16.
Bloom DA, Seeley WW, Ritchey ML et al (1993). Toilet
habits and continence in children: an opportunity
sampling in search of normal parameters. Journal of
Urology,149:1087-1090.
Bongers MEJ, Tabbers MM, Benninga M (2007). Functional
nonretentive fecal incontinence in children. Journal of
Pediatric Gastroenterology and Nutrition, 44:5-13.
Bongers MEJ, van Wijk MP, Reitsma JB et al (2010). Longterm prognosis for childhood constipation: clinicaloutcomes in adulthood. Pediatrics,126:e156-e162.
Candy D, Belsey J (2009). Macrogol (polyethylene glycol)
laxatives in children with functioanl constipationand faecal impaction: a systematic review. Archives of
Disease in Childhood, 94:156-160.
Cox DJ, Sutphen JL, Borrowitz SM et al (1998). Contributionof behavior therapy and biofeedback to laxative
therapy in the treatment of pediatric encopresis.
Annals of Behavioral Medicine, 20:70-76.
Felt B, Wise CG, Olsen A et al (1999). Guideline for the
management of pediatric idiopathic constipation andsoiling. Archives of Pediatric and. Adolescent Medicine,
153:380-385.

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Heron J, Joinson C, von Gontard A (2008). Trajectories ofdaytime wetting and soiling in a United Kingdom
4-to-9-year-old population birth cohort study. Journalof Urology,179:1970-1975.
Joensson IM, Siggard C, Rittig S et al (2008). Transabdominal
ultrasound of rectum as a diagnostic tool in childhood
constipation. Journal of Urology,179:1997-2002.
Joinson C, Heron J, Butler U et al (2006). Psychologicaldifferences between children with and without soilingproblems. Pediatrics,117:1575-1584.
Joinson C, Heron J, von Gontard A et al (2008). Early
childhood risk factors associated with daytime wetting
and soiling in school-age children. Journal of Pediatric
Psychology, 33:739-750.
Largo R, Gianciaruso M, Prader A (1978). [Die Entwicklung derDarm- und Blasenkontrolle von der Geburt bis zum
18. Lebensjahr]. Schweizer Medizinische Wochenschrift,
108:155-160.
Largo RH, Molinari L, von Siebenthal K et al (1996). Does a
profound change in toilet training affect developmentof bowel and bladder control? Developmental Medicine
and Child Neurology, 38:1106-1116.
Nurko S, Youssef NN, Sabri M et al (2008). PEG3350 in thetreatment of childhood constipation: a multicenter,double-blinded, placebo-controlled trial. Journal of
Pediatrics, 153:254-261.
Pijpers MAM, Tabbers MM, Benninga MA et al (2009).
Currently recommended treatments of childhood
constipation are not evidence based: a systematic
literature review on the effect of laxative treatment
and dietary measures. Archives of Disease in Childhood,
94:117-131.
Rasquin A, Di Lorenzo C, Forbes D et al (2006). Childhood
functional gastrointestinal disorders: child/adolescent.
Gastroenterology, 130:1527-1537.
van den Berg MM, Benninga MA, Di Lorenzo C (2006).
Epidemiology of childhood constipation: a systematic
review. American Journal of Gastroenterology, 101:24012409.
van der Wal MF, Benninga MA, Hirasing RA (2005). The
prevalence of encopresis in a multicultural population.
Journal of Pediatric Gastroenterology and Nutrition,
40:345-348.

9

IACAPAP Textbook of Child and Adolescent Mental Healthvon Gontard A (2010). [Enkopresis: Erscheinungsformen– Diagnostik – Therapie, 2nd ed)]. Stuttgart:
Kohlhammer.
von Gontard A, Neveus T (2006). Management of disordersof bladder and bowel control in childhood. London:
MacKeith Press.

World Health Organisation (2008). Multiaxial Classification ofChild and Adolescent Psychiatric Disorders: The ICD10 Classification of Mental and Behavioural Disorders
in Children and Adolescents. Cambridge: Cambridge
University Press.

von Gontard A, Baeyens D, Van Hoecke E et al (2011).
Psychological and psychiatric issues in urinary andfecal incontinence. Journal of Urology, 185:14321437.

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix C.5.1
TAKING A CLINICAL HISTORY OF ENCOPRESIS AND CONSTIPATION:
EXAMPLES OF QUESTIONS*
Presentation−
Do you know why you arehere?
−
Is it because you soil yourpants?
−
Do you want to talk aboutit?
Frequency of encopresis−
Does your child soil during
the day?
−
How often does he** soil
during the day (days per
week; days per month)?
−
How often does he soil
each day (times per day)?
−
At what time of day does
he usually soil (morning,
noon, in the afternoons,evenings)?
−
Does your child soil during
the night?
−
How often does he soil
during the night?
Symptoms−
If your child soils, howlarge are the stools (onlysmearing; smearing andstool masses; only stool
masses)?
−What is the consistencyof his stools (hard, soft,
watery – show the Bristol
Stool Chart)?
−
In which situations does
he soil?
−
Does he soil in stressful
situations?
−
Can he postpone
defecating if no toilet
is available, e.g. whiledriving? If yes, for how
long?
Relapses−
Has your child ever hada period in its life without
soiling?
−
If yes, what was thelongest period?
−
At what age did this occur?
−
Was there a reason for the
relapse (no, constipation,
diarrhea, pain while

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defecating, going tokindergarten, going toschool, birth of a sibling,
separation of parents,
other life events)?
Toileting behavior−
Does he wear a diaper?
−
If yes, when (during theday, at night only, both day
and night)?
−
How many days per week
does he pass stools into
the toilet?
−
How many times per day
does he defecate?
−
How large are the stools in
the toilet?
−
Do you have to send him
to the toilet? If yes, is thiseffective?
−
Does he enough time
when going to the toilet? Ifyes, how long?
−
Does he play or read while
sitting on the toilet?
Associated symptoms−
Does your child go to thetoilet regularly, at certain
times of the day? If yes,
when?
−
Does he have difficulty
passing stools?
−
Does he have to strain?
−
Is defecation painful?
−
What is the consistencyof the stools in the toilet(hard, soft, watery, withdifferent consistencies,
with blood – show Bristol
Stool Chart)?
−
Does he complain of
stomach or abdominal
pain? If yes, how often?
−
How strong is this pain?
−
When does he experience
stomach pains? Before orafter meals?
−
Is pain relieved after goingto the toilet?
−
Does he pass wind?

Perceptions andreactions after soiling−
Does your child noticewhen he has soiled?
−
Do you notice when he hassoiled?
−How do you notice it?
−
Does he tell you when hehas soiled?
−
If no, does he try toconceal it? Does he hide
his underpants?
−
How does he react when
he has soiled (indifferent,
no reaction, sad, anxious,
disappointed, ashamed,
desperate, angry or otherreactions)?
−
Who removes the stools
from the clothing (or thebed)?
−
Is he upset about thesoiling? If yes, how much?
−
If yes, how does this
distress show?
−
Is he motivated fortreatment?
Reaction of parents andothers in the child’s
environment−
How do you react whenyour child has soiled?
−
Are you distressed by his
soiling? If yes, how much?
−
Have you punished him
because of the soiling?
−
Do you think he soils on
purpose?
−Who knows that he soils?
−
Has he been rejectedby peers because of thesoiling? If yes, how?
−
How often does this occur?
−
Has he been unable totake part in activities
because of the soiling?
If yes, which activities(school outings, swimming,others)?
−
Does he engage in sports?
If yes, what sports?

Eating and drinking
habits−
How much fluid does yourchild drink per day?
−
Does he prefer to eat low
fiber foods? If yes, which
ones?
−
Does your child prefer to
eat other specific types offoods? If yes, which ones?
Previous treatment−
Has your child taken
laxatives? If yes, whichones? For how long?
−
Has he been examinedbecause of the soiling? If
yes, where and when?
−
Has he been treatedbecause of his soiling? If
yes, where and when?
−
What have you personallydone to treat the soiling?

Family history− Has anyone else in yourfamily soiled?
− Have members of yourfamily been affected byconstipation? Nighttime
or daytime wetting?
− Has anyone had
illnesses of the kidney,
stomach or bowels?
* von Gontard & Neveus, 2006;von Gontard, 2010.
**He or she as appropriate

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix C.5.2
ENCOPRESIS QUESTIONNAIRE – SCREENING VERSION*
Questions

Answers

Frequency of encopresis
Does your child soil during the day?

yesnoHow often does your child soil during the day?
How often does your child soil per day?

________

days per week________

days per month________

times per day

Does your child soil during the night?

yesno

How often does your child soil during the night?

________

nights per week________

nights per month

Encopresis symptoms
If your child soils, how large are the stool masses?

only smearing
smearing and stool masses
only stool masses

What is the consistency of your child’s stool?

hard
soft
wateryRelapses
Has your child ever had a period in its life without soiling?

yesno

If yes, at what age did this occur? - from age of_________

years; months_________

years; months

On how many days per week does your child pass stools into
the toilet?

________

days per week

How many times per day does your child defecate?

________

times per day- to age ofToileting behavior

How large are the stool masses in the toilet?

small
mediumlarge

Encopresis

C.5

12

IACAPAP Textbook of Child and Adolescent Mental Health

What is the consistency of your child’s stool in the toilet?

hard
soft
waterywith blood

Is defecation painful for your child?

yesnoDoes your child have stomach or abdominal pains?

yesnoPerceptions and reactions after soiling
Does your child suffer emotionally due to the soiling?

yesnoIs your child motivated for treatment?

yes

Have you punished your child because of its soiling?

yesnoWetting

How often does your child go to the toilet to urinate?

________

Does your child wet during the day?

Times per day
yesno

If yes, how often?

________

Does your child wet at night?

Days per weekyesnoIf yes, how often?

________

Days per week

How much fluid does your child drink per day?

_________ Litres per day*von Gontard and Neveus, 2006 ; von Gontard, 2010.

Encopresis

C.5

13

Encopresis

C.5

MondayTuesday*von Gontard and Neveus, 2006; von Gontard, 2010.

Sent to toilet (→)
Went alone (!)
Pants:Dry (D)
Wet (W)
Stools, small (S)Stools, large (L)Toilet:Urine (U)Stools (S)Evening

Sent to toilet (→)
Went alone (!)
Pants:Dry (D)
Wet (W)
Stools, small (S)Stools, large (L)Toilet:Urine (U)Stools (S)MiddaySent to toilet (→)
Went alone (!)
Pants:dry (D)
Wet (W)
Stools, small (S)Stools, large (L)Toilet:Urine (U)Stools (S)Morning

Date

WednesdayThursdayFridaySaturday

DOCUMENTING TOILET TRAINING (ENCOPRESIS CHART)*
SundayIACAPAP Textbook of Child and Adolescent Mental HealthAppendix C.5.3

14