And how to support children who have issues with soiling

For parents, potty training can be a practice in patience. It often involves masterful negotiation, knowing when to celebrate the small victories, and a whole lot of potty-related accidents!

But when a child has surpassed the potty-training stage — and they’re still having accidental bowel movements in their underwear — it might be time to seek outside help.

What is encopresis?

Encopresis, or soiling, is defined as consistent bowel movements anywhere other than the toilet after the age of four. The most common cause of encopresis for children is chronic constipation. This can happen when a child begins to avoid going to the bathroom due to how uncomfortable and/or painful constipation can be. And when they repeatedly hold in their bowel movements, poop starts to build up in their rectum and may start to back up into their colon.

One of the major roles of the colon is to remove water from your poop before it passes through the anus. And the longer a bowel movement stays in the colon, the dryer it becomes. This makes it harder to push out. The build-up of poop also causes the colon to stretch, weakening the sphincter — the muscle valve that passes feces out of the anus — and damaging the nerves that alert a child when it’s time to pass a bowel movement.

As new stool inevitably enters the colon but has nowhere to go, it can become watery and begin to leak out of the anus. And because of the nerve damage, the child can’t feel this happening. So, they’re often unaware that they’ve soiled their pants.

What are signs a child has encopresis?

While the child may not be able to feel it, the inevitable smell typically alerts those around them. And according to Sandra Whitehouse, PhD, the senior director of the Anxiety Disorders Center at the Child Mind Institute, this is usually how parents start to detect something is wrong.

“They'll notice odors, they'll notice that the child is soiling,” she explains. “And so, if you're noticing that your child tends to get constipated and tends to have trouble with soiling, and if the issue seems to be becoming a problem and a pattern, then it’s important to get it checked out medically.”

Signs of encopresis can also be found in the consistency of the child’s stool. Loose or watery poop can be a tell-tale sign, as well as irritation or a rash around the anal area. Your child may begin to hide their soiled underwear to keep you from finding out they’ve had an accident. They might become withdrawn. Odd behaviors in the bathroom such as tightening their bottoms, dancing around, crossing their legs, or crying and screaming can indicate an attempt to keep poop in rather than push it out.

If you suspect your child is having issues with their bowel movements, start keeping track of the soiling so you can bring this information to the doctor. “You're going to become a record keeper for about a week. You want to get a general feel for what times of the day it’s happening,” Dr. Whitehouse explains. “What days of the week is this happening? How often is the child using the toilet? Is there a pattern of a little bit of soiling or a lot of soiling? Can the child wipe themselves? Is it just that they simply aren't wiping themselves well? What else could be going on?” And according to Dr. Whitehouse, there are some really useful tracking apps you can download on your phone, such as Poop Tracker – Toilet Log.

How are children diagnosed and treated for encopresis?

Once you’ve collected the data, it’s time to go to your child’s pediatrician. They will be able to diagnose your child, begin treatment, and connect them with a specialist if needed. When discussing symptoms with the pediatrician, it’s helpful to mention your child’s eating habits along with their bowel movements. Diet can play a major role in chronic constipation.

To diagnose a child with encopresis, a doctor may conduct both a routine physical exam and a rectal exam to check for hardened, impacted stool. They may also recommend an x-ray of the child’s abdomen. And to treat symptoms, typically the doctor will:

Clear out the hardened poop from the rectum and colon. This can be done with medications such as laxatives or rectal suppositories. The doctor may also recommend an enema, a procedure that involves inserting liquid into the rectum through the anus to flush out the contents of the colon.
Help regulate the child’s bowel movements. A pediatrician will often prescribe stool softeners such as lactulose or mineral oil to make the passing of bowel movements more manageable. Your child may need to be on this medication for several weeks or months to give the bowels time to heal and return to their normal size. The doctor might also advise scheduled potty time after every meal that lasts about 5-10 minutes, so the child’s body can get used to going to the bathroom at regular times again. This will also help them re-learn what the urge to poop feels like.
Connect your child to a specialist or mental health professional. There are a variety of reasons why a child might develop chronic constipation and in turn, encopresis. Some are strictly health related, in which case the doctor will refer you to a neurologist or gastroenterologist, as the culprit may be a neurological or developmental issue involving digestion. But there can also be emotional challenges causing behaviors that lead to chronic constipation. If your doctor suspects this might be the case, they’ll suggest that your child see a mental health professional. This can also help the child cope with the emotional and social distress that often comes along with having encopresis.

Why might children develop encopresis?

There are a host of reasons why a child could be holding in their poop to this level of severity. Encopresis is often linked to anxiety, trauma, attention span issues, and more.

For instance, Dr. Whitehouse recalls having a patient who couldn’t sit still long enough to use the bathroom. “She was so bright and so full of energy. Sitting down on the toilet was boring. She wanted to do fun things, and she didn't quite have the attention span or the motivation to do the boring thing,” says Dr. Whitehouse.

She also points out that some kids get a “secondary gain” from having the disorder, such as getting to stay home from school. She recalls having a patient who just wanted to watch his favorite TV show. “He had a lot of siblings, and he said, ‘I am the little one in the house, and I never get to choose what's on TV — until one day I had an accident, and everybody left the room,’” she says. “So with him it was about working closely with his family to give him more control and making things a little bit more fair for him at home.”

Regardless of how they might’ve developed the disorder, it’s important that kids aren’t made to feel ashamed or bad for soiling themselves. And having this common goal of finding a solution can even be playful.

As Dr. Whitehouse and her TV-loving patient continued to work together, the boy started to affectionately call her, “Dr. Poop House.”

How can parents help their child at home?

Manage diet and exercise: Once a child has been diagnosed with encopresis, parents or caregivers need to work with the doctor to regulate bowel movements. Part of this involves changes in diet and exercise. Adding fresh fruits, beans, and vegetables high in fiber to the child’s meals and snacks will help keep their stool soft and regular. Here are a few examples of simple ways you can add more fiber to their diet.

Explain how the body operates: If you’ve figured out that your child is encopretic, it can help for them to understand — at an age-appropriate, developmentally appropriate level — what's happening in their body, says Dr. Whitehouse.

She describes using visual aids to talk to her patients about encopresis. “I'll draw a picture of intestines and say, ‘If you don't poo, it just sits in there and it's like a big old brick in the middle of your intestines. And then the poo leaks around that, and that's why it comes out in your underpants. And what you got to do is get rid of that whole big brick because then your system works.’”

This way, kids will have a better understanding of why they might need to take stool softeners or rectal suppositories to clear out their bowels. And they’ll be more motivated to work on the behaviors that contribute to their chronic constipation.

Use rewards: To keep kids motivated, have a reward system for when they use the bathroom. They can get coupons, or “poop-ons,” as a reward for engaging in healthy pooping habits. This can especially come in handy when they’re having their designated 5–10-minute bathroom time after each meal, as recommended by their pediatrician.

“If they sit on the toilet for five minutes, they could get one poop-on that's worth a certain number of points. And if they actually produce something, they can get two poop-ons,” says Dr. Whitehouse. “And then those can be turned in for rewards that they can earn, like 15 minutes of special time with a parent, or they get to choose the family activity for the night. Or maybe they're earning towards something, like a toy that they want to buy.”

How does encopresis affect children’s mental health?

Having encopresis can take a toll on a child’s social, emotional, and mental health.

“I've known children who aren’t sure if they might've leaked. And to check themselves, they’ll simply put their hand down their pants. And then a kid catches them doing that, and they get teased mercilessly when they're just trying to figure out what's going on in their own bodies,” says Dr. Whitehouse. “Because this is a behavior that's observable by others, it can have pretty devastating consequences socially for a child.”

This can lead to social isolation, low self-esteem, and social anxiety. So, if you start to notice that your child is withdrawing from you and/or their peers, it can be helpful to seek further mental health support.

And at home, you can help to validate their feelings as you navigate the disorder together. “You really want to help the child to identify the emotions they're feeling, validate those emotions,” Dr. Whitehouse advises. “And so, you're acknowledging and using that opportunity to build closeness with your child. And you’re also telling them, ‘Many people have problems with pooping, lots of kids have trouble with encopresis. We got this. Let's come up with a plan to address it.’”

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What Is Encopresis?