Pediatric encopresis and occupational therapy

Today I had contact with three families who were all dealing with problems relating to encopresis. Encopresis can be essentially defined as a lack of fecal continence and it is a huge problem for families. I have to admit that there was no training in my occupational therapy curriculum relating to encopresis, although occupational therapists spend a lot of time talking about helping people with self care activities of daily living. I suppose that my educational programs assumed that intervention ends when a child can let their pants down and sit on the potty?

The lack of any mention of pediatric encopresis in the occupational therapy literature certainly doesn't stop occupational therapists from weighing in on this subject when it comes to giving parents advice. I read an evaluation once where a therapist talked about a child's constipation and encopresis being related to a craving for deep pressure stimulation, and it was a reflection of poor sensory processing. The recommended treatment was to provide the Wilbarger protocol every two hours until bowel habits became more regular. Recently I had another parent ask me if there were sensory contributions to encopresis and I had to admit that there is no evidence in the literature to suggest that.

So what is the evidence about encopresis? A Cochrane Revew review (2006) identified that behavioral interventions when used together with laxative therapy may improve continence in children with non-organic fecal incontinence and constipation. Biofeedback interventions did not seem to have any positive effects. So in trying to help one family with this problem we tried writing a social story as a cognitive-behavioral strategy to improving continence. The parents are still ruling out medical issues - so I am not sure what the answer will be.

The literature points to several difference issues relating to encopresis that OTs need to be aware of. There are significant psychological differences between children who have encopresis and peers who do not (Cox, Morris, Borowitz, & Sutphen, 2002). However, not all of those differences fall within the range of 'clinical significance' on behavioral measures.

In another study, Klages, et.al. (2005) found that children who had early onset Bipolar I disorder were more likely to have encopresis and atypical/hostile mother-child interaction. When writing that it is reminiscent of autism and refrigerator-mom research, but I think their point was that children who have encopresis also had disturbed parental relationships as part of an overall 'phenotype' to Bipolar I disorder.

In another study Johnston and Wright (1993) identified a co-morbidity between encopresis and attention problems. In sum, kids who had encopresis had much higher (clinically significant) scores on the Hyperactive subscale of the CBCL.

These different studies all point out interesting facts about encopresis. Some children who have encopresis have measured differences on their CBCL scores, but not all of those differences are in the range of clinical significance. Some kids have elevated hyperactivity CBCL scores that are clinically significant. Another group of kids have encopresis associated with more severe mental illness, specifically Bipolar I disorder. For intervention, laxatives probably help and cognitive-behavioral approaches probably help.

So are there sensory factors? I suppose one could argue about the nature of the term 'sensory.' It seems that children who have encopresis may have some difficulties with attention and therefore 'regulatory' function. Perhaps there is a subset of children who have encopresis related to decreased ability to attend to internal messages that they need to go to the bathroom. We still need to gather more information before we recommend brushing programs for children like this though.



References:

Brazzelli M, Griffiths P. (2006) Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children (Cochrane Review). The Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD002240.

Cox, D.J., Morris, J., Borowitz, S.M., & Sutphen, J.L. (2002). Psychological differences of children with and without chronic encopresis. Journal of Pediatric Psychology, 27, 585-591.

Johnston, B.D., Wright, J.A. (1993). Attentional dysfunction in children with encopresis. Journal of Developmental and Behavioral Pediatrics, 14, 381-385.

Klages, T., Geller, B. Tillman, R., Bolhofner, K., & Zimerman, B. (2005). Controlled study of encopresis and enuresis in children with a prepubertal and early adolescent bipolar-I disorder phenotype. Journal of the American Academy of Child Adolescent Psychiatry, 44(10), 1050-7.