Beha\. Res & Therap?. 197X. Vol 16. pp. W-21? 0 Pergamon Press. Ltd Prmted m Gwdt Brilam

CASE HISTORIES AND SHORTER COMMUNICATIONS

A simple behavioral treatment program for psychogenic encopresis

(Received 8 September 1977)

Summary-A treatment program based on behavioral psychological principles which can be explained to parents in one session and supervised by letters and phone calls each week was found to be highly effective in completely eliminating the problem of psychogenic encopresis. A controlled study and extensive clinical use have indicated IOO”, effectiveness for the program when carefully adhered to.

Encopresis or fecal soiling of the clothes beyond the time when the child should have been successfully toilet trained is a frequent complaint of parents. On examination these cases are sometimes found to result from poor and unsuccessful toilet training of the child. Instruction in proper toilet training is required in these cases.

In other cases, examination of the patient may reveal organic pathology sufficient to account for the condition. Principally. this tends to be in the form of disease or dietary factors resulting in diarrhea. Adequate diagnostic and treatment procedures exist for these sources of the difficulty. Interestingly, in the majority of the cases encountered it is found that rather than fecal material being forcefully expelled resultmg in soiling, fecal material is being retained producing chronic constipation accompanied by megacolon (Wright. 1973). In these cases the soiling results from seepage around the impacted fecal material through a sometimes partially dilated anus. Organic causes of megacolon include obstruction and neurological disorders. especially Hirschprung’s disease (Nevin, 1975; Swenson, 1951). However, soiling is generally absent in cases of organic megacolon. In a large number of cases presenting with fecal impaction accompanied by soiling. no organic condition exists which accounts for the symptoms (Richmond. Eddy, and Garrard, 1954). These are referred to as functional or psychogenic cases of megacolon and should be distinguished from organically caused megacolon, which requires considerably different treatment usually including surgical intervention, Levine has recently presented an extensive descriptive analysis of encopretic children. Eighty out of the 102 cases of non-organic encopresis seen during an 18 month period at the Medical Diagnostic Clinic at the Children’s Hospital Medical Center in Boston were found to have stool impaction accompanying their fecal incontinence (Levin, 1975). Fitzgerald (1975) in commenting on the Levine article indicated that in his experience. more than 95:; of their encopretic patients were impacted.

A common assumptton among psychodynamically oriented psychologists and psychiatrists m such cases is that the fecal retention is a result of some psychological problem such as hostility, rebellion. tension or depression (Bell and Levme. 1954; Olatawura. 1973). Premature or overly strict attempts at toilet training are also frequently menttoned (Freedman. Kaplan and Sadock, 1975). However treatment of the problem by means of counseling or psychotherapy is generally considered difficult. requiring fairly long and intenstve therapy with relatively meager results (Yates. 1970).

On the other hand. numerous articles in recent years (e.g. Allyon, Simon and Wildman. 1975: Bach and Moylan, 1975; Doleys and Arnold. 1975; Keehn. 1965: Neale. 1963) have demonstrated that prmctples of operant conditioning are extremely effective in eliminating this problem. However. most of the reports are case studies based on one subject and the techniques employed were often sufficiently unique to the particular circumstances of the patient that they could not be used without modification for other patients. None of the programs were tested on numerous patients. with adequate data collection. The present article describes a systematic treatment program that can be applied in step by step fashion to cases of psychogenic encopresis with virtually no changes from patient to patient. It has been used at the University of Oklahoma Medical School over a period of 5 years with over 100 cases.

The program. which is usually completed in approximately four months, has been carefully researched and is found to be virtually loo”,, successful if properly applied. While completion of the program generally requires four months. the psychologist or physician need have only minimal involvement after the first session. The procedure for the treatment program is as follows:

1. A careful physical examination and any necessary tests should be accomplished to rule out the possibility of an organic etiology to the problem.

2. Interview with parents and the child to rule out the possibility of serious psychopathology or emotional disturbance. Psychological testing may be required in some cases to rule out the possibility of underlymg emotional disorders. However. this is not generally required. If the child is seriously disturbed m the sense of being psychotic or near psychotic. it may be well to attend to the more serious psychologtcal disturbance and delay treatment of the encopresis until some improvement in the more sertous problem is realized. However. if the child appears to be symptom free or has only moderate personal problems it may be well to institute the program. Inevitably, improvement is seen in the general functioning and emotional stability of the child and the family as a side benefit to treatment of the encoprests. Family and/or individual therapy may be employed to deal with problems remaining after the encopresis has ceased. However. in most cases, we have found this to be unnecessary.

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210 CASE HISTORIES AND SHORTER COMMUNICATIONS

3. The parents are instructed m the details of the program. They are the ones who explain it to the child.

However, the therapist may on occasion also want to explain it to the child if for any reason he feels the parents would have difficulty doing this or that it would be better for him to explam it.

4. The treatment program consists of the following components. (a) To begin the program, the child’s colon should be evacuated. Generally an enema the night before the program begins is sufficient. In rare cases. a short series of enemas or manual procedures by a physician may be required. (b) Once the initial cleaning out process has been completed. the parents are mstructed to follow a program of having the child go to the bathroom immediately upon awakenmg m the mornmg. Other times of the day can be substituted if the morning time is impractical. However. this is a good time physiologically and in terms of the life style of most people. Therefore. the morning is usually used. The parents supervise this attempt. If the child produces a reasonable amount of feces at this point. he is praised and given a small reward and the day proceeds with breakfast. preparing for school. etc. The reward is used as an incentive to remforce the child for trying as hard as he can and is agreed upon m advance. Choice of rewards is discussed under section e. (c) If the child does not produce a reasonable amount. say at least &i_t cup (we use household measures because the mother is generally the one supervising the process). of feces on his own. the parent inserts a glycerin suppository and permits the child to dress. have breakfast. and prepare to leave for school. By the time the child is finished with breakfast. the suppository will usually have its effect and the child can be taken back to the bathroom where he makes another attempt to defecate. If he is successful this time. he receives a reward. This reward should be smaller than the one for defecating entirely on his own. (d) If shortly before time to leave for school arrives and no defecation has taken place. the parent gives the child an enema to produce defecation, It is important that the enema chosen be one that is safe for repeated administration and that side effects be watched and controlled should they occur. In practice. we used Fleet’s enemas. but others could be employed. Seldom are enemas given with sufficient frequency to constitute a hazard. However. caution is required in cases where they are necessary with any degree of frequency. Enemas may be decreased to one every other day or ev’ery third day m cases where prolonged use (1 per day for more than 10 days) is required. In most cases. the child will be able to evacuate on his own. with only an occasional suppository or enema. after the first few days of the program. No reward is given if an enema is needed to produce defecation. Essentially. defecation must occur every morning. or at the appointed time each day, during the program (except in instances. as noted above. where overuse of enemas becomes a problem-then the evacuation must occur regularly every other day or every third day). While it is true that it is not necessary for a person to defecate every day. as a traming technique during the program, it must be insured that the child defecates rrgultrrl~~ and it is preferable that he do so daily. This insures that the child’s colon will regain its normal shape and tone and provides ample opportunity for training in good toilet habits. Following the mornmg training period and defecation. the child leaves for school. (e) At the end of the day. the child‘s clothing is examined. This is done at a specified time, e.g. after school. after supper, shortly before bedtime. or some other suitable time. If there is no soiling. he receives a reward. If there is soiling. he receives a mild punishment. Proper use of rewards and punishments are crucial to the success of this program. The program requires two rewards (one for defecating and one for not soiling) and one punishment (for soiling). It often takes careful and astute questioning of the parents and child to determine suitable rewards and punishments. Careful interviewing is required. It is of great importance that the reinforcement be one which is v’ery compelling and that the pumshment be one the child definitely wants to avoid. Among the rewards that we have found most successful in this program are such things as money, candy. small toys (such as soldiers), praise. extra privileges. tickets to recreation events. etc. One of the most effective rewards and one that is quite general m that it works with most children is allotting them a certain period of time. say 20 or 30 mmutes. at the end of the day m which their parents will do anything they ask. They may want to play checkers or ride piggy-back or talk with the parents and have the parents read a book to them or somethmg of that sort. But. it can be specified that they will receive, as a reward for not soiling for the day. a specified amount of parental attention which they can use in any way they want. This is usually a very effective reward and one that obviously has beneficial side effects in promoting interaction and pleasant association between the parent and child. The effectiveness of this reward may also be due, m part. to the fact that it gives the child a socially acceptable way of controlling his environment and manipulating his parents rather than the socially unacceptable and relatively ineffective means he was using. i.e.. soiling. As Indicated. choice of the punisher should also be made carefully. Some of the punishments that we have found effective are restriction of television vtewing. loss of privileges. monetary fines. and havmg to do extra chores (es- pecially chores of siblings). One of the more effective pumshments is for the child to sit m a chair for a given period of time. Thus, if the child does not soil during the day he may be allotted 20 or 30 minutes of parental time. On the other hand. if he does soil. he may be required to sit in a chair for a specified amount of time. The rewards and punishments once selected are delivered daily as indicated in the preceding steps of the program. Rewards are given in the mornmg for defecation (unless an enema is used) and a reward or pumshment is given in the evenmg depending on whether or not soiling has occurred. For example. a typical program might involve 25c if the child defecates on his own in the morning, 1Oc if a suppository is required. and 30mm of parental time (we often use the child’s name to label this e.g. “Billy Time”) if no soiling occurs during that day. If soiling occurs, the child must sit in a chair for 15 mm. (f) The above regime is continued on a daily basis without interruption. Smce many parents are fairly discouraged about ever finding anything that will help with the problem. it is a good idea to let them know that you understand how they feel. Then present the program to them in a positive manner and

CASE HISTORIES AND SHORTER COMMUNICATIONS 211

explain that it virtually never fails. if carried out properly. It is also important to stress to the parents that they must be IOClq; consistent in this program and that it must be done whether or not they feel well, whether or not they are visiting friends or any other activity that may be going on in the household. This is important because people frequently think of numerous reasons to depart from the program and obviously the program will not work if it is not being employed. The parents are instructed to keep a daily notebook of exactly what was done. This notebook should be kept much like a lab book when one is conducting an experiment. They should indicate what time the child arose, exactly what transpired during the bathroom procedure, whether or not there was defecation. the amount, whether or not the reward was given, the child’s reaction, and any other pertinent details. They should then record. later in the day, the results of the inspection, the reward and/or punishment which was delivered and some note about how the child seems to be feeling or doing on the program. This written report is mailed to the office at the end of each week.

In addition. a phone call contact is made with the family each week. The phone call is generally timed to come a day or so after the written report has been received. On the phone it is possible to give additional support. encouragement. or advice and to deal with any problems that may come up during the program.

Basically, the main problem that occurs is that the parents for one reason or another begin to become lax in following the program. It is important to keep track of what they are doing on a day by day basis from their written report and the phone calls in order to encourage them to be IOO”,, consistent in following the program. If they have concerns or difficulties. these can be discussed and they can be reassured about them. Dietary advice and use of stool softeners can be discussed and recommended during the phone conversations. if and when they appear to be needed.

Often parents fail to send in the written reports or fail to make the phone calls. If the therapist wants the program to be successful, he will have to depart from standard procedure and place a phone call to the patient. We usually tell our patients in advance that we will call them if they don’t call us. If the patient does not call. the therapist needs to get in touch with them in order to keep them working on the program consistently. Most patients seem to appreciate the interest and attention of an occasional phone call and it has a considerable motivating effect on them to know that the therapist cares enough to follow-up. In our experience careful follow-up has been found to be essential. When the follow-up is exact and compulsively carried out, the program worked. When the follow-up is lax. the program does not get carried out properly and does not work. (g) After two consecutive weeks in which no soiling has taken place, it is time to begin phasing out the program. To do this. one day during the week is selected in which the cathartics will not be employed. The remainder of the program continues as usual. If no soiling occurs for one week following discontinuing of the cathartics for the day selected, an additional day off the cathartics is added for the following week. The days should generally be selected to be some distance apart such as beginning with a Thursday and then adding a Monday. etc. Days can then be added to the program each week in which no soiling occurs by inserting days equidistant from the days already off the program. This is continued until the child is completely free of soiling and completely off cathartics. At this point the reward and punishment program is terminated. While this may seem abrupt, the habit is generally well-established by this time and being free of soiling is sufficiently rewarding to maintain it.

If soiling occurs at any time during the phase-out period, the procedure used is to retreat one step and start over again. That is, if the child has worked his way up to three days off the program and soils, he then moves back to two days off the program and five days on. If another soiling occurs, he backs up to one day off the program and six days on, etc. Often soiling persists during this period. with the child working up to 4 or 5 days off the program, then falling back to two or three, back up to four or five, etc. When this occurs, it is important to determine if the soiling is due to incontinence or failure to clean one’s self carefully following a bowel movement. If the latter is the case. use of Tucks or other instructions regarding careful cleansing may be given. It often helps to give an enema the morning following each soiling. The added motivation to avoid enemas, along with thorough evacuation, generally results in cessation of the soiling. This program generally alleviates the encopretic problem in approximately 15 to 20 weeks. One benefit that seems to occur with most of the children in such a program is that they spontaneously begin to show improvement in other areas of their lives. That is, they begin to be happier, feel more self-confident. respond to discipline better, work better in school and in various other ways show progess toward maturity. It may be that their previous inability to control their bowels had a depressing effect on their general functioning. That is, if one can’t even control his bowels how can he hope to exert any kind of influence on anything else in his life or think of himself as able to cope successfully with the world. On the other hand, when he discovers that he can handle this problem and do so successfully, the child often becomes more optimistic about his ability to deal with other kinds of problems and other situations. He also, at this point, is subject to less teasing by peers and less conflict with parents, teachers, and others. At any rate. children on the program generally show signs of improvement in other behaviors as well as the encopresis. If the child appears to have additional or persisting problems following the treatment of encopresis, it is of course, appropriate to provide additional counseling and therapy.

The above program takes approximately a half hour to an hour of the therapist’s time at the initiation of the program and a few minutes each week to supervise the program. It is also obvious that, if an assistant is care- fully instructed in the procedures, he/she could handle many details of the case management. However, it is essen- tial that the person managing the case be thoroughly familiar with principles. All of the materials (enemas. suppositories. stool softeners. and Tucks) may be obtained without prescription from a local pharmacy.

The above described program was developed by the senior author of this paper and has been used with over 100 subjects in the Division of Pediatric Psychology at the University of Oklahoma Health Sciences Center. In all cases where the program has been applied rigorously and consistently by the parents, the program was found to be successful. There were approximately IO-15% refusals on the part of the parents

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212 CASE HISTORIES AND SHORTER COMMUNlCATlONS

in following the program schedule, and the plan had to be terminated either before it began or in the early stages. There have been no failures of the treatment modality itself.

While the program seems somewhat complicated and rigorous, we have had good success in getting parents of even marginal intellectual ability and of lower socio-economic status to carry out the program. However, they do require more prompting and supervision than other patients.

Careful data were gathered on 14 subjects in a research project dealing with the program. This study is reported in more detail elsewhere (Wright, 1975). There were 12 male and 2 female subjects ranging from three to nine years of age. Three of the 14 subjects had never achieved bowel control, three began soiling after bowel training had been accomplished but following a critical family incident such as divorce, death. or birth of a new sibling, while the eight remaining subjects began soiling after bowel training had been achieved but no critical incident could be identified. The mean length of time for completion of the program for the fourteen subjects was 16.93 weeks, with a range from 10 to 38 weeks. Although one subject required 38 weeks to completely stop soiling, only four of the subjects were still soiling after the fourteenth week of treatment. The average number of soiling incidents per week reduced from 17 lo 2 within one week. This initial burst of success is very reinforcing lo parents and enables them to carry out the program with considerable enthusiasm. All subjects studied in the research project ceased soiling by the end of the treatment regime. On a six month follow-up only one subject had begun soiling again. Subjects who regress following the program, generally respond quite well to initiation of the same program again. The second time through generally takes less time and there has never been a second relapse. The above program is felt to offer a practical, economical, and effective means of treating the encopretic child.

Department of Pediatrics Oklahoma Children’s Memorial

Hospital, Health Sciences Center.

Oklahoma City, Oklahoma 73190. U.S.A

LOGAN WRIGHT C. EUGENE WALKER

REFERENCES

AYLLON T., SIMON S. J. and WILDMAN R. W. II. (1975) Instructions and reinforcement in the elimination of encopresis: A case study. J. Behav. Ther. Exp Psychiar. 6, 235-238.

BACH R. and MOYLAN J. J. (1975) Parents administer behavior therapy for inappropriate urination and enco- presis: A case study. J. Behav. Ther. Exp. Psychiat. 5, 239-241.

BELL A. I. and LEVINE M. I. (1954) The psychologic aspects of pediatric practice: Causes and treatment of chronic constipation. Pediatrics 14, 259-265.

DOLEYS D. M. and ARNOLD S. (1975) Treatment of childhood encopresis: Full cleanliness training. Mental Retard. 13, 14-16.

FITZGERALD J. F. (1975) Encopresis, soiling, constipation: What’s to be done? Pediatrics 56, 348-349. FREEDMAN A. M., KAPLAN H. I. and SADOCK 9. J. (1975) Encopresis. In Comprehensioe Textbook of Psychiaq

(2nd Ed.). Williams & Wilkins, Baltimore. KEEHN J. D. (1965) Brief case-report: Reinforcement therapy of incontinence. Behau. Res. Therap. 2. 239. LEVIN M. D. (1975) Children with encopresis: A descriptive analysis. Pediatrics 56, 412. NEALE D. H. (1963) Behavior therapy and encopresis in children. Behac. Res. Therap. 1, 139-149. NEVIN R. W. (1975) Discussion on megacolon and megarectum with the emphasis on conditions other than

Hirschprung’s disease. Proc. R. Sot. Med. 54, 348-349. OLATAWURA M. 0. (1973) Encopresis: A review of thirty-two cases. Acta paediar. scan. 62, 358-364. RICHMOND J. 9.. EDDY E. J. and GU~RARD S. D. (1954) The syndrome of fecal soiling and megacolon.

Am. Orthopsychiat. 24, 391-401. SWENSON 0. (1951) Congenital megacolon (Hirschprung’s disease). Pediatrics 8, 542. WRIGHT L. (1973) Handling the encopretic child. Pro& Psycho/. 4, 137-144. WRIGHT L. (1975) Outcome of a standardized program for treating psychogenic encopresis. Prof: Psycho/.

6. 453456. YATES A. J. (1970) Behavior Therapy. John Wiley, New York.