Why do so many children learn to have bowel movements in their potty chair, only to regress when using the potty seat on a toilet? Why do some children who have been successfully potty trained suddenly start having bowel movements anywhere
A Vicious Cycle
In the absence of a medical problem, a particular chain of events can lead to a lot of resistance or even full-blown encopresis — chronic soiling. It often begins when a child is slightly constipated, so the stool is a bit harder than normal. When it lands in the toilet bowl, the cold water splashes, hitting his bottom. The combination of surprise and discomfort makes the youngster nervous, even a bit afraid, of having a B.M. in the toilet again. He becomes tense and starts trying to hold in bowel movements to the point that he becomes constipated. When he does manage to have another bowel movement, the hard stools are painful to pass and produce more splashing.
A vicious cycle develops if a child is reluctant to pass stool for any reason, and he can become increasingly constipated. Bowel movements become increasingly hard and painful, which further adds to the child's reluctance to pass them. The situation can escalate to the point that a mass too large and hard to pass through the rectum forms in the bowel. Liquid which can't be absorbed leaks around the mass and exits. The child cannot inhibit the flow. Chronic, involuntarily soiling occurs.
Even slight constipation stemming from any cause can turn into a full-blown case of encopresis. Often, parents have no idea what is happening. The child has no control and can't feel when he is soiling.
Treatment for Encopresis
To break the cycle, the first step is to overcome problems with constipation. If that isn't enough, check with your child's pediatrician about mineral oil or a stool softener that will, once it takes effect, prevent him from holding it in. The oil may take a few days to work, so if your toddler is extremely constipated, a glycerin suppository or enema may help him get started. Since mineral oil can interfere with vitamin absorption, administer it several hours after a meal or before bedtime. Mixing the mineral oil in juice can make it more palatable.
A typical starting dose of mineral oil is 1 teaspoon per ten pounds of body weight given at night, or divided into ½ teaspoon at morning and at night. The daily dose can be increased to three teaspoons. If you give too much, it may leak out, leaving stains on your child's underwear. Because mineral oil increases the risk of vitamin depletion, consult your pediatrician to see if your child needs a multivitamin. If the bowel movements become too frequent or watery, the dosage should immediately be reduced.
Create Positive Associations
Because children in this situation have come to associate the potty with physical pain and discomfort, breaking the negative associations and creating new, more positive ones may take a while and require a lot of help. Once the mineral oil takes effect and the child has been having regular soft bowel movements for ten days, rectal soreness should be completely healed. At that point, it is time to help your child have bowel movements while sitting on the potty.
For starters, have your child sit on the toilet for five minutes every day at the time he usually has a B.M., wearing pull-ups to ensure he is not splashed. If his resistance is too strong to be overcome by reassurance and pep talks alone, offers of toys and special privileges may be necessary. Provide a reward for just sitting on the toilet. Have him engage in a quiet activity he enjoys, such as reading a book to him, playing with an Etch-A-Sketch, or reciting nursery rhymes.
Protect your encopretic child from getting splashed by cold water when having a B.M., as this can lead him to withhold stool again. Have him stick to a potty chair until he is over his fears of having B.M.s, then reintroduce him to the toilet.
Once reluctance about sitting on the toilet has been overcome (meaning he sat without a struggle for three days in a row for five minutes each time), and he is completely healed, up the ante by making rewards contingent on having a bowel movement while sitting on it, but leave his pull-ups on to prevent splashing. If he doesn't go during his daily five-minute regime of sitting on the toilet, provide verbal praise and tell him he can still earn the reward if he has a B.M. in the toilet later. Instruct him to tell you when he needs to use it.
After a week of regular bowel movements while sitting on the toilet, your child should be ready to try having a bowel movement into the toilet. Remove his pants. Continue to set a timer to ensure he sits for five minutes, but only provide a reward after he actually uses the toilet, which might be later in the day.
Parents can begin reducing the mineral oil at any time the stools have remained consistently soft. Eliminate it gradually over a two-week period. Don't be surprised if the problem flares up again. Do what you can to protect your child from further psychological harm. Many people, including some psychologists, believe this kind of chronic soiling is a very disturbed way to express repressed anger. Adults' aversion to chronic soiling and lack of familiarity with the causes and cures has contributed to the belief even among many professionals that encopresis is a severe mental or behavioral disorder. Indeed, the stigma is so intense and peers' reactions may be so unfavorable, sufferers can quickly develop serious psychological problems. Children with this medical problem are often depressed, socially maladjusted, and have behavior disorders. But that is the result of this problem, not the cause.
If caught early and treated with compassion, there is nothing to suggest encopretic children have more serious adjustment problems than a child who has never experienced this problem.