Elimination Disorders

Enuresis and encopresis are the two elimination disorders described in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). These disorders are considered after age 4 years for encopresis and after age 5 years for enuresis, when a child is chronologically, developmentally, and physiologically expected to be able to master these skills. Normal development encompasses a range of time in which a given child is able to devote the attention, motivation, and physiological skills to exhibit competency in elimination processes. Encopresis is defined as a pattern of passing feces in inappropriate places, such as in clothing or other places, at least once per month for 3 consecutive months, whether the passage is involuntary or intentional. The child with encopresis typically exhibits dysregulated bowel function, for example, with infrequent bowel movements, constipation, or recurrent abdominal pain and sometimes pain on defecations. Encopresis is a nonorganic condition in a child who is chronologically at least 4 years old. Enuresis is the repeated voiding of urine into clothes or bed, whether the voiding is involuntary or intentional. The behavior must occur twice weekly for at least 3 months or must cause clinically significant distress or impairment socially or academically. The child’s chronological or developmental age must be at least 5 years.

ENCOPRESIS

Epidemiology

Incidence rates for encopretic behavior decrease drastically with increasing age. Although the diagnosis is not made until after age 4 years, encopretic behavior is present in 8.1 percent of 3-year-olds, 2.2 percent of 5-year-olds, and 0.75 percent of 10-to 12-year-olds. In Western cultures, bowel control is established in more than 95 percent of children by their fourth birthday and in 99 percent by the fifth birthday. Encopresis is virtually absent in youth with normal intellectual function by the age of 16 years. Males are found to be about six times more likely to have encopresis than females. A significant relation exists between encopresis and enuresis.

Etiology

Encopresis involves an often-complicated interplay between physiological and psychological factors. Although encopresis is considered a nonorganic disorder, a typical child with encopresis may show evidence of chronic constipation, leading to infrequent defecation, withholding of bowel movements, and avoidance of defecation. Children may avoid the pain of having a bowel movement by holding it in, which then leads to impaction and eventual overflow soiling. This pattern is observed in more than 75 percent of children with encopretic behavior. This common set of circumstances in most children with encopresis supports a behavioral intervention with a focus on ameliorating constipation while increasing appropriate toileting behavior. Inadequate training or the lack of appropriate toilet training may delay a child’s attainment of continence.

Evidence indicates that some encopretic children have lifelong inefficient and ineffective sphincter control. Other children may soil involuntarily, either because of an inability to control the sphincter adequately or because of excessive fluid caused by a retentive overflow.

Encopresis has been demonstrated to occur with significantly greater frequency among children with known sexual abuse compared with a normal sample of children, and it occurs with greater frequency among children with a variety of psychiatric disturbances compared with controls. Encopresis, however, is not a specific indicator of sexual abuse because it also occurs with increased frequency in nonabused children with other behavioral problems. Some evidence indicates that encopresis in children is associated with measures of maternal hostility and harsh and punitive parenting. A recent study evaluating the frequency of encopresis and enuresis in children with prepubertal and early adolescent bipolar I disorder found a greater prevalence of encopresis among children with bipolar disorder compared with healthy controls; in most cases, however, the encopresis predated the onset of the affective illness.

It is evident that once a given child has developed a pattern of withholding bowel movements with resulting pain with attempts to defecate, a child’s fear and resistance to changing the pattern can lead to a power struggle between child and parent over effective toileting behavior. Perpetual battles often aggravate the disorder and frequently cause secondary behavioral difficulties. Many children with encopresis who are not reported to have early behavioral problems end up being socially ostracized and rejected because of the encopresis. The social consequences of soiling can further lead to the development of psychiatric problems. On the other hand, children with encopresis who clearly can control their bowel function adequately but chronically deposit feces of relatively normal consistency in abnormal places are more likely to have a preexisting neurodevelopmental problem, easy distractibility, short attention span, low frustration tolerance, hyperactivity, or poor coordination. Occasionally, a child has a specific fear of using the toilet, leading to a phobia.

In some children, encopresis can be considered secondary, that is, emerging after a period of normal bowel habits in
conjunction with a disruptive life event, such as the birth of a sibling or a move to a new home. When encopresis manifests after a long period of fecal continence, it may reflect a response indicative of a developmental regressive behavior, for example, based on a severe stressor, such as a parental separation, loss of a best friend, or an unexpected academic failure.

Psychogenic Megacolon.

Most children with encopresis retain feces and become constipated, either voluntarily or secondarily to painful defecation. In some cases a subclinical preexisting anorectal dysfunction exists that contributes to the constipation. In either case, resulting chronic rectal distention from large, hard fecal masses can cause loss of tone in the rectal wall and desensitization to pressure. Thus, children in this situation become even less aware of the need to defecate, and overflow encopresis occurs, usually with relatively small amounts of liquid or soft stool leaking out.

Anecdotal reports indicate that children whose parenting has been harsh and punitive and who have been severely punished for “accidents” during toilet training are at greater risk of developing encopresis.

Diagnosis and Clinical Features.

According to DSM-IV-TR, encopresis is diagnosed when feces are passed into inappropriate places on a regular basis (at least once a month) for 3 months (Table 43-1). Encopresis may be present in children who have bowel control and intentionally deposit feces in their clothes or other places for a variety of emotional reasons. Anecdotal reports have suggested that occasionally encopresis is attributable to an expression of anger or rage in a child whose parents have been punitive or of hostility at a parent. In a case such as this, once a child develops this inappropriate repetitive behavior eliciting negative attention, it is difficult to break the cycle of continuous negative attention. In other children, sporadic episodes of encopresis can occur during times of stress—for example, proximal to the birth of a new sibling—but in such cases, the behavior is usually transient and does not fulfill the diagnostic criteria for the disorder.

Encopresis can also be present on an involuntary basis in the absence of physiological abnormalities. In these cases, a child may not exhibit adequate control over the sphincter muscles either because the child is absorbed in another activity or because he or she is unaware of the process. The feces may be of normal, near-normal, or liquid consistency. Some involuntary soiling occurs from chronic retaining of stool, which results in liquid overflow. In rare cases, the involuntary overflow of stool results from psychological causes of diarrhea or anxiety disorder symptoms.

Table 43-1 DSM-IV-TR Diagnostic Criteria for Encopresis

A.	Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional.
B.	At least one such event a month for at least 3 months.
C.	Chronological age is at least 4 years (or equivalent developmental level).
D.	The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation.
Code as follows:
With constipation and overflow incontinence
Without constipation and overflow incontinence
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.

The DSM-IV-TR breaks down the types of encopresis into with constipation and overflow incontinence and without constipation and overflow incontinence. To receive a diagnosis of encopresis, a child must have a developmental or chronological level of at least 4 years of age. If the fecal incontinence is directly related to a medical condition, encopresis is not diagnosed.

Studies have indicated that children with encopresis who do not have gastrointestinal illnesses have high rates of abnormal anal sphincter contractions. This finding is particularly prevalent among children with encopresis with constipation and overflow incontinence who have difficulty relaxing their anal sphincter muscles when trying to defecate. Children with constipation who have difficulties with sphincter relaxation are not likely to respond well to laxatives in the treatment of their encopresis. Children with encopresis without abnormal sphincter tone are likely to improve over a short period.

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