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Journal of Pediatric Psychology, Vol. 25, No. 4, 2000, pp. 255-256
© 2000 Society of Pediatric Psychology
Commentary: Treatment of Encopresis: Where Do We Go From Here?
University of Cincinnati
All correspondence should be sent to Lori J. Stark, Children's Hospital Medical Center/University of Cincinnati School of Medicine, Division of Psychology, 3333 Burnet Avenue, Cincinnati, Ohio 45229. E-mail: lori.stark{at}chmcc.org .
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Perhaps the most surprising aspect of the review on treatments that work for encopresis is how little we know about how to treat this disorder. Encopresis is one of the first problems addressed by the field of pediatric psychology in demonstrating the utility of an integrated approach of psychology and pediatrics in the treatment of physical disorders of children (Wright & Walker, 1978
). It
also has a high prevalence rate compared to other chronic conditions of
childhood, representing about one-quarter of the referrals to the pediatric
subspecialty of gastroenterology. Despite pediatric psychology's long history
with the disorder and the high prevalence rate of encopresis, our approach to
treatment and the methodology employed to examine treatment outcome are still
in their infancy.
One barrier to conducting more sophisticated treatment outcome studies is
the state of medical treatment for the disorder. General guidelines for
treating children presenting with constipation and constipation with
incontinence exist, but there is little treatment information in the medical
literature for children presenting with soiling without constipation. As
pointed out by the authors of the current review, these subcategories of the
diagnosis of encopresis are rarely specified yet are likely critical for
advancing our knowledge of effective treatments. In the medical treatment of
constipation with or without incontinence, the actual implementation of
treatment varies, sometimes due to practitioner bias and not data on actual
efficacy or side effects. For example, medical treatment of constipation with
or without bowel incontinence typically calls for a bowel cleanout followed by
a treatment regimen (laxatives, mineral oil) to soften feces and maintain
daily bowel movements. However, the specific regimen for a bowel cleanout can
vary and includes enemas, suppositories, and large doses of mineral oil or a
balanced electrolyte colonic lavage solution given by mouth or nasogastric
tube. One argument that has been made for the use of oral methods of bowel
cleanout is that enemas may be "psychologically unsuitable"
(Gleghorn, Heyman, & Rudolph,
1991). However, there is little empirical data to support such an
assertion; some survey data indicate that, although children find enemas
difficult, over half of the children treated with this modality reported
enemas to be useful (Bernard-Bonnin, Haley,
Belanger, & Nadeau, 1993). Pediatric psychology can make a
significant contribution to the treatment of this disorder by examining the
impact of the various medical approaches on children's adjustment
posttreatment. We can evaluate not only the efficacy but the potential
"side effects" and thus help practitioners to make data-based
treatment decisions.
A second limitation of psychological interventions for encopresis is sample
selection. Most of the studies reported, including research conducted by my
colleagues and I, have used convenience samples: children referred for
psychological treatment after failing medical management. Research has rarely
taken the approach of prospectively recruiting children with this disorder and
randomly assigning them to treatment groups. One potential reason for this is
the lack of funding to conduct clinical trials in encopresis. Although we
recognize the significant impact encopresis can have on a child's social and
emotional functioning, we have not used this information to advocate and seek
the funding necessary to conduct treatment outcome research. In fact, in a
search of the NIH grant award database, only one such grant was found
(Cox, 1992). The barriers to
seeking funding and conducting such research are unclear. One barrier may be
the illusion that we have proven and effective treatments for this disorder.
Almost all studies in the area report high levels of success
(Walker, 1995). However, one of
the benefits of the series on "Empirically Supported Treatments in
Pediatric Pychology" is that it allows us to step back and evaluate
where we have been and where we still need to go. The studies described in the
current review of interventions for encopresis provide a strong foundation for
developing well-established treatments. The review also accurately points out
the next steps to advance the empirical test of psychological treatments.
Encopresis is a disorder for which we have many "promising"
treatments. I think it is time that pediatric psychology take the research on
this problem to the next level and conduct the clinical trials necessary to
fully document the efficacy of behavioral treatment.
Received November 20, 1999; accepted November 20, 1999
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Bernard-Bonnin, A. N., Haley, N., Belanger, S., & Nadeau, D. (1993). Parental and patient perceptions about encopresis and its treatment. Developmental and Behavioral Pediatrics, 14, 397-400.
Cox, D. (1992). Treatment of early childhood constipation and encopresis. NIH Grant # 5R01HD28160-07.
Gleghorn, E. E., Heyman, M. B., & Rudolph, C. D. (1991). No-enema therapy for idiopathic constipation and encopresis. Clinical Pediatrics, 30, 669-672.
Walker, C. E. (1995). Elimination disorders: Enuresis and encopresis. In M. C. Roberts (Ed.), Handbook of pediatric psychology, 2nd ed. New York: Guildford Press.
Wright, L., & Walker, C. E. (1978). A simple behavioural treatment program for psychogenic encopresis. Behaviour Research and Therapy, 16, 209-212.[Medline]
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