Ask the expert: My grandson is defecating in his underpants several times a day

Q I am writing to you about my five- year-old grandson. For the past year he has been defecating in his underpants several times a day. He is the eldest of two children and my daughter is expecting another baby in April.

My daughter is a psychotherapist and took him to see a psychologist last year who said it was due to “birth trauma”.

When she asked my grandson why he does it, he said it was because he doesn't want her to go to work. After seeing the psychologist my daughter took two months off work and the problem seemed to dissipate. However, not surprisingly, it is not an option for her to give up work and this is very distressing for us all.

My daughter says he doesn't do it when he is with her. Can you give us some guidance so we can help him?

A When a child beyond the age of toilet training (five-plus) is regularly defecating or soiling their underpants, they have a condition called encopresis. Unfortunately, encopresis is a common problem that can be stressful and embarrassing for both children and parents to handle.

Sadly, it is a problem that is frequently misunderstood by parents and professionals alike.

While encopresis generally has a physical cause (namely constipation – see later), many people attribute emotional causes such as “birth trauma”, for which there is not much evidence. Sometimes people think the child is soiling on purpose when usually the child is not fully in control of their bowel movements.

These explanations can be unhelpful because they can lead to the child feeling blamed. It can also increase conflict between parent and child, making the problem worse. For example, the child can become more embarrassed and then hide their bowel movements.

The causes

Encopresis usually starts out with a child getting into a habit of “holding on” to his poos and avoiding going to the toilet. Frequently, this habit starts because the child has a bad experience using the toilet (perhaps experiencing pain making a bowel movement due to constipation). However, over time, as he continues to “hold on” and avoid using the toilet, he becomes more constipated. He then reaches a point where he begins to lose control of how and when he has a bowel movement.

In severe cases, his bowels become so impacted with hard poo, that he loses control altogether and the stools begin to leak out at different intervals during the day.

Overcoming encopresis takes time and patience on the part of children and parents, and usually involves the three components below.

Treating constipation

The first thing to do is to get your grandson’s level of constipation assessed by a doctor. Your GP might do this or they might refer to a specialist. There are usually two phases of treatment. The first one is to use laxatives or enemas to clear the impacted colon and the second is a more sustained use of laxatives or enemas as your son relearns to control his own bowel and use the toilet correctly.

Positive retraining

The second step is to retrain your grandson to use the toilet. This means that his parents and carers should never give out or criticise him when he soils and instead always remain supportive and encouraging.

A good way to approach this is to sit down and explain the problem to him, discussing a plan to overcome it together. A good strategy is to use a child-like name for the problem such as “sneaky poo”. You can use this name to overcome the issue together.

This means that when he has an accident, you can take the criticism out of it and direct it towards “sneaky poo”, saying “Oops, did sneaky poo surprise you again? Not to worry, next time we will try to get him in the toilet.” This is a form of narrative therapy that you can learn more about on dulwichcentre.com.au.

The goal of positive training is to help your grandson gradually relearn to control his bowels. As his constipation clears, he will be able to tune into the signals from his body that his bowel is full so he can go to the toilet. In particular, you want to help him break the habit of “holding on” to his poos and instead visit the toilet the minute he feels the slightest inclination.

During the retraining you can use reward charts to keep him motivated and to make the process fun. For example, to encourage him to sit on the toilet a few times a day, he might get a star each time he tries and a special one each time he is successful.

You can make the visits to the toilet fun by playing music there or reading stories together. You can also give him the reward of blowing bubbles when he sits on the toilet. The act of blowing a bubble mirrors the same bodily signal of relaxing bowels so all this can help.

Diet and exercise

Diet and exercise also play a part in preventing constipation. A high intake of sugars, fats, highly processed foods and a sedentary lifestyle all contribute to constipation.

While changing diet won’t change severe constipation – which is likely to need medical help – by increasing fresh fruits, fibre and other healthy foods in your grandson’s diet, you make constipation less likely to reoccur.

Getting further help

There are some great websites that have excellent information on overcoming encopresis and related problems. In particular, I recommend work by Steve Hodges, an urologist in the US. He has some child-friendly charts that you can use to explain bowel movements and the problem to your grandson. www.See bedwettingandaccidents.comThere is also an excellent article on http://kidshealth.org with more detailed information.

Dr John Sharry is a social worker and psychotherapist and co-developer of the Parents Plus Programmes. He will be delivering courses on Positive Parenting for teens in Cork on Saturday, March 12th, and a series of talks on promoting self- esteem and overcoming anxiety in children in Dublin on Mondays, starting on April 11th. See solutiontalk.ie for more details.