Case Study #1

CASE #6: ERIC

Eric is an eight-year old only child who was brought to the clinic by his parents, who were very concerned about his behavior of defecating his pants at home and at school. When they first came to the clinic the parents were insistent on speaking with the clinician first, with Eric not in the room. Obviously embarrassed by her blushing, Eric’s mother confessed that over the past six months he has soiled his pants approximately once a week. In the past week, it has increased to once a day. She described him as a normal baby and was potty-trained by twenty-eight months.

Until the past six months, no toileting accidents have taken place. A second grader earning all As, Eric has never been the most popular kid. He does have two good friends who have continued to play with him despite his “accidents.” Eric’s father is concerned if his behavior does not stop, the other children will tease him.

With his parents insisted on not being in the room, Eric entered alone carrying a book. When questioned, Eric said he was very happy but never had time to read. His parents always wanted him to play outside, but two best friends also enjoyed reading and playing “pirates.” He described how he used reading to ignore the kids who teased him on the bus.

Eric began to squirm when asked about the “accidents.” He stated he really didn’t mind except his parents were really upset and he didn’t want to lose his friends. He explained that when it did happen he was either ready or playing pirates and did not want to stop. Eric grimaced and said, “Yuck, that’s gross,” when asked why he never urinated his pants.

The diagnosis was Encopresis, Secondary Type. DSM-IV Made Easy (2006) lists four criteria for Encopresis: * Accidentally or on purpose, the patient repeatedly passes feces into inappropriate places (clothing, on floor). * For at least three months, this has happened at least once per month. * The patient is at least four years old (or the developmental equivalent). * This behavior is not caused solely by the use of substances (such as laxatives) or by a general condition (except through some mechanism that involves constipation). * Secondary Type is diagnosed in Eric’s case because his Encopresis developed after a period of fecal continence.

To avoid Eric viewing himself as “psychologically disturbed,” he was not sent to therapy. While there was no constipation reported, he was to have a medical exam to rule out colon issues. Once rules out, therapy was initiated with the parents to begin a behavior modification program. Eric chose reading time as his top reinforcer. With the help and persistence of his parents, and the guidance of the therapist, Eric had no new “accidents” after five weeks.

RESEARCH

In researching this topic, I found that most encopresis cases (90%) are due to functional constipation, which is constipation that has no medical cause (KidHealth, 2011). Left untreated, this is a medical problem that soon can become an emotional problem. While parents and caregivers often blame the accidents on behavioral issues, the child carries a deep sense of shame and anger because they don’t know what is wrong, but they do know they aren’t doing it on purpose.

Approximately 80-95% of children with encopresis have a history of constipation or painful bowel movements (Borowitz, 2010). Causes other than constipation may be related to a lack of toilet training, toilet training to early, conduct disorder, or emotional disturbance such as oppositional defiant disorder (A.D.A.M., 2011). The Mayo Clinic (2011) describe signs and symptoms of encopresis that may include: Leakage of stool, constipation with hard stool, passage of large stool that clogs, avoidance of bowel movements, long periods between movements, lack of appetite, abdominal pain, or repeated urinary tract infections. It’s time to call the doctor when your child, who is older than four and already potty-trained, starts to show one or more of these symptoms.

The first step in treatment is clearing the colon of retained, impacted stool. Regular, healthy bowel movements are encouraged after that. A diet high in fiber and adequate fluid intake will promote the passage of softer stools and minimize the discomfort associated with bowel movements. As a counselor-in-training intending to work in the school setting, I am concerned about the emotional and psychological impact associated with this disorder. It is crucial that parents remain supportive and refrain from criticism or discouragement. Consequences and punishments for these accidents leave the child feeling even more alone, angry, depressed, or humiliated. KidsHealth (2011) reports that up to 20% of kids with encopresis experience feelings of low self-esteem that require the intervention of a psychologist or counselor.

REFERENCES

A.D.A.M. Medical Encyclopedia. (2011). Encopresis: Soiling; Incontinence – Stool. Atlanta, GA: A.D.A.M. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002537/ Borowitz, S. (2010). Encopresis: Epidemiology. Medscape, PubMed Health. http://emedicine.medscape.com/article/928795-overview#a0199 KidsHealth. (2011). Encopresis (Soiling). The Nemours Foundation. http://kidshealth.org/parent/general/sick/encopresis.html Mayo Foundation for Medical Education and Research. (2011). Encopresis. The Mayo Clinic. http://www.mayoclinic.com/health/encopresis/DS00885/METHOD=print Morgan, R.K. (1999). Case Studies in Child and Adolescent Psychopathology. Upper Saddle River, NJ: Prentice-Hall.

Morrison, J. (2006). DSM-IV Made Easy: The Clinician’s Guide to Diagnosis. New York, NY: The Guilford Press.