Tuesday 26 September 2017

Dear David Coleman: My five-year-old keeps soiling herself. Please help!

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David Coleman

David Coleman

Clinical psychologist David Coleman offers parenting advice in his weekly column.

Q. I have major concerns about my five-year-old daughter. She has never done a poo in the toilet. She toilet trained for wees fairly quickly and was fully trained more or less overnight.

Pooing is a different story. She goes in her pants every time and that doesn't bother her one bit. I have tried everything, bribed her, praised her, you name it, nothing is working.

I am at my wit's end and I have been told by my public health nurse to be patient, but it's going on a long time now. I have been wondering if it's some psychological issue?

David replies: Encopresis is the correct term to describe soiling. Primary encopresis is when a child has never successfully established a toileting habit for their poo and has always soiled, to a greater or lesser extent.

Secondary encopresis refers to a situation where a child had successfully toilet trained and was in the habit of using the toilet to poo, but then at some later age, began to soil themselves.

Sometimes, secondary encopresis can be triggered by a bad bout of constipation, but it can also be caused by trauma or significant emotional distress for a child. Secondary encopresis, most often, has a psychological component to it.

A psychological issue is less often the cause of primary encopresis, which, from your description, is what your daughter has. However, when the soiling continues, it can create a very negative dynamic in a household, leading to lots of distress and conflict between parents and the child.

It is good that you are motivated to help your daughter change things. One of the biggest impacts that you can have as a parent in relation to soiling, is to remain calm, matter-of-fact, but firm about the toileting routines you are helping her to set up.

Even though you may feel frustrated or angry, it won't help the situation to act angrily. When parents get annoyed, children can often lose motivation to focus positively on their toileting.

Establishing healthy toileting habits does require a readiness on the part of the child. We need our children to be aware of the physical sensation of their bowel being full and to be conscious about the release of their muscles to allow a stool to pass.

We all rely on the physical signal of the distension in our bowel to tell us that we need to poo. If that signal is weakened because a child holds a lot of poo in their bowel leading the muscles to be overstretched and lose sensitivity, then it can be difficult for them to know that they need to go to the toilet.

So, it might be worth getting a medical check-up to ensure that your daughter is not constipated and that her bowel isn't full and overstretched.

Another difficulty, if there is a blockage, is that the stool can become impacted in their intestine or bowel, such that what leaks out is very liquid and the child may not even sense that the liquefied stool is coming out.

If this is an issue, then your GP may recommend a course of laxatives to try to re-establish a regular bowel function.

Assuming that her bowel is working normally, your main goal is to get her into the habit of sitting on the toilet, being ready to poo. To do this, you can keep an eye on her toileting rhythms to see if there is a typical time, or times, in the day when she poos.

Either using this as a guide, or just bringing her to the toilet after every meal, you will encourage her to sit on the toilet, being ready to poo.

You can reinforce this sitting by offering stars, points, or small rewards, such that she knows that there is a benefit to her to sit on the loo! Staying with her in the bathroom, you can distract her with stories, chat or songs.

With luck, she will take the opportunity to poo and then you can reward her for that, with a slightly bigger treat or increased praise.

Even if she doesn't poo at those times, she still gets reinforced for just sitting.

Should an accident occur at some other time, then pay little attention to it, other than matter-of-factly helping to clean her up, encouraging her to "finish" the poo in the toilet.

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