Treatment guidelines for primary nonretentive encopresis and stool toileting refusal.
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Nonretentive encopresis refers to inappropriate soiling without evidence of fecal constipation and retention. This form of encopresis accounts for up to 20 percent of all cases. Characteristics include soiling accompanied by daily bowel movements that are normal in size and consistency. An organic cause for nonretentive encopresis is rarely identified. The medical assessment is usually normal, and signs of constipation are noticeably absent. A full developmental and behavioral assessment should be made to establish that the child is ready for intervention to correct encopresis and to identify any barriers to success, particularly disruptive behavior problems. Successful interventions depend on the presence of soft, comfortable bowel movements and addressing toilet refusal behavior. Daily scheduled positive toilet sits are recommended. Incentives may be used to reinforce successful defecation during these sits. A plan for management of stool withholding should be agreed on by the parents/caretakers and the family physician before intervention. (+info)
Empirically supported treatments in pediatric psychology: constipation and encopresis.
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OBJECTIVE: To review the empirical research examining behavioral and medical treatments for constipation and fecal incontinence. METHOD: Sixty-five articles investigating intervention efficacy were identified and reviewed. Twenty-three of the studies were excluded because they were case studies or were less well-controlled single-case designs. The intervention protocol for each study was identified and coded, with studies employing the same interventions matched and evaluated according to the Chambless criteria. RESULTS: From the literature base to date, no well-established interventions have emerged. However, four probably efficacious treatments and three promising interventions were identified. Two different medical interventions plus positive reinforcement fit the criteria for the probably efficacious category (one with fiber recommendation and one without). Three biofeedback plus medical interventions fit efficacy category criteria: one probably efficacious for constipation with abnormal defecation dynamics (full medical intervention plus biofeedback for paradoxical contraction), and two fit the promising intervention criteria for constipation and abnormal defecation dynamics (full medical intervention plus biofeedback for EAS strengthening, correction of paradoxical contraction and home practice; and biofeedback focused on correction of paradoxical contraction, medical intervention without fiber recommendation, and positive reinforcement). Two extensive behavioral interventions plus medical intervention also met efficacy criteria for constipation plus incontinence (medical intervention without laxative maintenance plus positive reinforcement, dietary education, goal setting, and skills building presented in a small-group format fits criteria for a promising intervention; and positive reinforcement and skills building focused on relaxation of the EAS during defecation, but without biofeedback, plus medical intervention meets the probably efficacious criteria). CONCLUSIONS: A discussion of the current weaknesses in this research area follows. Specific recommendations for future research are made including greater clarity in treatment protocol and sample descriptions, reporting cure rates rather than success rates, utilization of adherence checks, and investigation of potential differential outcomes for subgroups of children with constipation and incontinence. (+info)
Psychological differences between children with and without chronic encopresis.
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OBJECTIVE: To validate a theoretical model of encopresis in terms of psychological factors that differentiates children with and without chronic encopresis and to identify scales that demonstrate these differences. METHODS: Eighty-six children with encopresis were compared to 62 nonsymptomatic children on five psychometric instruments. Differences in the mean scores and the percentages of children falling beyond preselected clinical thresholds were compared across the patient-control groups. RESULTS: Children with encopresis were found to have more anxiety/depression symptoms, family environments with less expressiveness and poorer organization, more attention difficulties, greater social problems, more disruptive behavior, and poorer school performance (ps =.01 < or =.001 on 15/20 subscales). There were no differences in self-esteem. On those subscales where proportionately more encopretic children exceeded clinical thresholds, approximately 20% more of the encopretic children exceeded thresholds than control children. CONCLUSIONS: As a group, children with encopresis differ from children without encopresis on a variety of psychological parameters. However, only a minority of children with encopresis demonstrated clinically significant elevations in these parameters. Identification and treatment of such clinical issues may enhance treatment efficacy. (+info)
Physiopathology of megarectum: the association of megarectum with encopresis.
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Studies of both rectosphincteric reflex threshold and conscious rectal sensitivity threshold were performed on 15 control subjects and 61 children with a radiological megarectum, 70% of whom were encopretics. In control subjects, the reflex threshold and the sensitivity threshold were obtained with a comparable volume of rectal distension. In the megarectum patients, sensitivity was often considerably reduced, the incidence of encopresis increasing proportionally with the decrease in conscious rectal sensitivity. Patients were segregated in three functional groups, according to measurements of the sensitivity threshold. (+info)
Assessment of behavioral mechanisms maintaining encopresis: Virginia Encopresis-Constipation Apperception Test.
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OBJECTIVE: To develop and test a scale for parent and child, evaluating theoretical and clinical parameters relevant to children with encopresis. Encopretic children were hypothesized to have more bowel-specific, but not more generic, psychological problems, as compared with nonsymptomatic control children. In addition, mothers were also believed to be more discerning than children. METHODS: The Virginia Encopresis-Constipation Apperception Test (VECAT) consists of 9 pairs of bowel-specific and 9 parallel generic drawings. Respondents selected the picture in each pair that best described them/their child. It was administered to encopretic children (N = 87), nonsymptomatic siblings (N = 27), and nonsymptomatic nonsiblings (N = 35). The mothers of all the participants also completed the VECAT. Encopretic children were retested 6 and 12 months posttreatment with Enhanced Toilet Training. RESULTS: The VECAT demonstrated good test-retest reliability and internal consistency. Encopretic children and their mothers reported more bowel-specific, but not more generic, problems. Bowel-specific scores improved significantly posttreatment only for those patients who demonstrated significant symptom improvement. Mothers were significantly more discerning than children. CONCLUSION: The VECAT is a reliable, valid, discriminating, and sensitive test. Bowel-specific problems appear to best differentiate children with and without encopresis. (+info)
Colonic transit times and behaviour profiles in children with defecation disorders.
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AIMS: To evaluate children referred for defecation disorders using the child behavioural checklist (CBCL). METHODS: A total of 215 patients were divided into three groups: 135 (5-14 years of age) with paediatric constipation (PC), 56 (5-17 years) with functional non-retentive faecal soiling (FNRFS), and 24 (5-16 years) with recurrent abdominal pain (RAP). Behavioural scores were correlated with colonic transit time (CTT) and anorectal function parameters (manometry and EMG). RESULTS: No significant differences in the mean CBCL scores were found among the three patient groups. However, children with PC and FNRFS had significantly more behavioural problems than the Dutch normative sample, while children with RAP had scores within the normal range. No significant differences were found between CTT in the patient groups, with respect to the CBCL. Similarly, no significant difference existed between children able or unable to relax their pelvic floor muscles during defecation attempts and their behaviour profiles. CONCLUSION: There seems to be no relation between colonic/anorectal function and specific behavioural profiles. On the other hand, children with defecation disorders show more behavioural problems than do controls. (+info)
Nurse management of intractable functional constipation: a randomised controlled trial.
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AIMS: To evaluate the effectiveness of a nurse led clinic (NLC) compared with a consultant led paediatric gastroenterology clinic (PGC) in the management of chronic constipation. METHODS: Children (age 1-15 years) with functional constipation were randomised following a detailed medical assessment to follow up in either the NLC or PGC. An escalating algorithm of treatment was used as the basis of management in both the NLC and PGC. Main outcome measures were: time to cure at last visit or later confirmed by telephone; time to cure at last visit; and time to prematurely leaving the study. RESULTS: A total of 102 children were recruited, of whom 52 were randomly assigned to NLC and 50 to PGC. Outcome assessment showed that 34 children in the NLC and 25 children in the PGC were confirmed cured at their last visit or later confirmed by telephone. The median time to cure was 18.0 months in the NLC and 23.2 months in the PGC. The probability of being cured was estimated as 33% higher in the NLC compared to PGC (hazard ratio 1.33). Attending the NLC hastened time to cure by an estimated 18.4%. CONCLUSION: Children who attend an NLC are equally as, if not more likely to be cured of intractable constipation, than those attending a PGC and on average their cure will occur sooner. Results suggest that an NLC can significantly improve follow up for children with intractable constipation and highlight the important role for clinic nurse specialists in management of children with gastrointestinal disease. (+info)
Prognosis of constipation: clinical factors and colonic transit time.
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BACKGROUND: Measurement of colonic transit time (CTT) is sometimes used in the evaluation of patients with chronic constipation. AIM: To investigate the relation between symptoms and CTT, and to assess the importance of symptoms and CTT in predicting outcome. METHODS: Between 1995 and 2000, 169 consecutive patients (median age 8.4 years, 65% boys) fulfilling the criteria for constipation were enrolled. During the intervention and follow up period, all kept a diary to record symptoms. CTT was measured at entry to the study. RESULTS: At entry, defecation frequency was lower in girls than in boys, while the frequency of encopresis episodes was higher in boys. CTT values were significantly higher in those with a low defecation frequency (< or =1/week) and a high frequency of encopresis (> or =2/day). However, 50% had CTT values within the normal range. Successful outcome occurred more often in those with a rectal impaction. CTT results <100 hours were not predictive of outcome. However, those with CTT >100 hours were less likely to have had a successful outcome. CONCLUSION: The presence of a rectal impaction at presentation is associated with a better outcome at one year. A CTT >100 hours is associated with a poor outcome at one year. (+info)