Refusal of Requested Treatment -- the Case of Baby Lv
Handling Guidelines for Chief Nonretentive Encopresis and Stool Toileting Refusal
Am Fam Physician. 1999 Apr 15;59(viii):2171-2178.
Run into related patient information handout on toddlers who don't want to apply the toilet, written by the authors of this article
Article Sections
- Abstruse
- Guideline one: Place Potential Medical, Developmental or Behavioral Pathology
- Guideline 2: Address Toilet Refusal Behavior
- Guideline 3: Ensure Soft, Well-Formed Stools
- Guideline 4: Schedule Prompted Toilet Sits
- Guideline 5: Provide Incentives for Appropriate Bowel Movements and Self-Initiation
- Guideline half dozen: Conform for Doctor Contact in Case of Stool Withholding
- Illustrative Case
- References
Nonretentive encopresis refers to inappropriate soiling without evidence of fecal constipation and memory. This class of encopresis accounts for up to 20 percent of all cases. Characteristics include soiling accompanied by daily bowel movements that are normal in size and consistency. An organic cause for nonretentive encopresis is rarely identified. The medical assessment is usually normal, and signs of constipation are noticeably absent. A full developmental and behavioral cess should be made to establish that the child is prepare for intervention to right encopresis and to identify any barriers to success, specially disruptive beliefs problems. Successful interventions depend on the presence of soft, comfortable bowel movements and addressing toilet refusal behavior. Daily scheduled positive toilet sits are recommended. Incentives may be used to reinforce successful defecation during these sits. A program for direction of stool withholding should exist agreed on past the parents/caretakers and the family doctor before intervention.
Encopresis affects 1 to 3 percent of children, with higher rates in boys than in girls.one,2 However, encopresis may go undetected unless health professionals directly inquire about toileting habits.3
From 80 to 95 percent of encopresis cases involve fecal constipation and retention.iv Although several excellent reviews cover retentive encopresis,5–7 encopresis in which fecal retentiveness is not a primary etiologic component is nether-represented in the literature. Typically, children with the latter condition soil on a daily ground, with bowel movements of normal size and consistency. Various terms have been used to draw this trouble, including functional encopresis, primary nonretentive encopresis and stool toileting refusal. These children may be further divided into at least iv subgroups: (1) those who fail to obtain initial bowel training, (2) those who showroom toilet "phobia," (iii) those who use soiling to "manipulate" their environment and (4) those who accept irritable bowel syndrome. Although the toileting dynamics and behavioral characteristics of children with nonretentive encopresis are well described,8–ten few specific treatment guidelines are available for family physicians.
While the treatment of retentive encopresis has progressed substantially in the by 20 years, less attention has been paid to the v to 20 percent of cases in which constipation is not contributory, or where a kid "refuses" the toilet-training process. The family physician is likely to be the outset to identify this problem and to provide "front line" intervention. Occasionally, a child presents who is non physically, cognitively or emotionally prepared for toilet training. In these cases, waiting until the child matures is the sensible choice. Yet, many times the reason is not a lack of readiness skills, but a kid who is behaviorally resistant or parents who need data on effective beliefs management or toilet-training strategies.eleven
Once the reason for a kid'southward resistance is identified, specific interventions tin can be initiated. If the trouble is related to a skill deficit (east.g., opening the bath door, disrobing, seating self on the toilet, wiping), and so modeling, teaching and reinforcement are preferred to passive waiting. In like fashion, if the child is oppositional or noncompliant with adult instructions, the md may choose to refer the family unit to a pediatric psychologist who is familiar with compliance training protocols. In either case, without agile intervention, the "stiff-willed" kid may resist toilet training, create unnecessary stress on the parent-child relationship and increase the risk of abuse.12
This article provides handling guidelines for children with principal nonretentive encopresis or stool toileting refusal. The guidelines were adult from the literature on toilet training and encopresis, with a special emphasis on practicality and ease of implementation by the family doc. The illustrative case presented on page 2176 shows the efficacy and simplicity of these treatment guidelines.
Guideline one: Identify Potential Medical, Developmental or Behavioral Pathology
- Abstruse
- Guideline 1: Identify Potential Medical, Developmental or Behavioral Pathology
- Guideline ii: Accost Toilet Refusal Beliefs
- Guideline 3: Ensure Soft, Well-Formed Stools
- Guideline 4: Schedule Prompted Toilet Sits
- Guideline 5: Provide Incentives for Appropriate Bowel Movements and Self-Initiation
- Guideline 6: Arrange for Dr. Contact in Case of Stool Withholding
- Illustrative Instance
- References
MEDICAL
First, a consummate physical examination is indicated when a child presents with a history of soiling. The history and physical exam may be the only diagnostic tools necessary to identify retentive encopresis and related organic factors. Few cases of retentive encopresis and even fewer cases of nonretentive encopresis have an organic etiology.xiii,xiv Table ane summarizes pertinent aspects of the history and physical exam. The principal differential diagnoses of encopresis are listed in Table two.13–15
TABLE 1
History and Physical Test in Children with Toileting Refusal and Soiling
| History | |
| Stool pattern | |
| Size | |
| Consistency | |
| Interval | |
| History of constipation | |
| Historic period of onset | |
| History of soiling | |
| Age of onset | |
| Blazon and amount of material | |
| Diet history | |
| Type and amount of food | |
| Changes in diet | |
| Decrease in appetite | |
| Abdominal pain | |
| Medications | |
| Urinary symptoms | |
| Day or dark enuresis | |
| Urinary tract infection | |
| Family unit history of constipation | |
| Family or personal stressors | |
| Physical examination | |
| Height | |
| Weight | |
| Intestinal exam | |
| Distention | |
| Mass, particularly suprapubic | |
| Rectal test | |
| Sacral dimple | |
| Position of anus | |
| Anal fissures | |
| Anal wink | |
| Sphincter tone | |
| Rectal vault size | |
| Presence or absence of stool in rectum | |
| Pelvic mass | |
| Neurologic examination | |
TABLE 2
Differential Diagnosis of Encopresis
| Retentive | |
| Functional constipation (95 percentage) | |
| Organic (v percent) | |
| Anal causes | |
| Fissures | |
| Stenosis/atresia with fistula | |
| Inductive displacement of anus | |
| Trauma | |
| Postsurgical repair | |
| Neurogenic causes | |
| Hirschsprung's disease | |
| Chronic intestinal psuedo-obstruction | |
| Spinal cord disorders | |
| Cerebral palsy/hypotonia | |
| Pelvic mass | |
| Neuromuscular affliction | |
| Endocrine/metabolic causes | |
| Hypothyroidism | |
| Hypercalcemia | |
| Lead intoxication | |
| Drugs | |
| Codeine | |
| Antacids | |
| Others | |
| Nonretentive | |
| Nonorganic (99 percent) | |
| Organic (1 per centum) | |
| Astringent ulcerative colitis | |
| Acquired spinal cord disease (i.e., sacral lipoma, spinal string tumor) | |
| Rectoperineal fistula with imperforate anus | |
| Postsurgical damage to anal sphincter | |
Children with retentive encopresis often soil pocket-sized quantities of loose fecal matter several times a day but periodically laissez passer very large bowel movements. They may present with urinary complaints and abdominal pain or distention. The concrete examination is usually suggestive of constipation.
A consistent soiling pattern characterized by stools that are normal in size and consistency and the absence of constipation usually suggests nonretentive encopresis. If the medico is unable to confirm the presence of constipation or impaction following the history and physical examination, a apartment plate radiograph of the abdomen will help in diagnosis. Farther diagnostic investigation using laboratory tests, barium enemas, rectal manometry or biopsy is reserved for apply in children who fail conservative therapy or whose history and physical examination suggest an organic etiology. Finally, Hirschsprung'south disease is oftentimes mentioned in the differential diagnosis of encopresis; however, children with Hirschsprung's disease do not typically pass large bowel movements and rarely soil.thirteen
DEVELOPMENTAL
Unrealistic expectations or family priorities (particularly the nascence of another child) may prompt parents to begin toilet training earlier the kid is developmentally prepared.16 Physicians can employ the fifteen- or 18-month well baby visit to inquire about plans for toilet training and to ensure that both the child and the family are gear up for the process. Initiating training when parents are under fourth dimension constraints or during periods of family unit accommodation and stress volition be difficult.
Child readiness is determined by the presence of the prerequisite physiologic, developmental and cognitive/psychologic skills to principal the complexities of independent toileting. Physiologic readiness is demonstrated by sphincter control, which is commonly nowadays by the fourth dimension the kid crawls or walks,17 and by bladder and bowel readiness, shown by the ability to remain dry for several hours at a time and to fully empty the bladder on voiding.
Some children make facial expressions, assume certain body postures (e.g., squatting) or go to a specific location to urinate or defecate. Developmental criteria include attainment of major motor skills such as existence able to walk to the bathroom, sit on the toilet, lower and raise pants and flush the toilet. Cerebral/psychologic readiness criteria involve both receptive language adequate to understand toileting-related words such as "moisture," "dry," "pants" and "bathroom," and instructional readiness, as indicated by a child who desires to imitate and please parents and to follow simple instructions. Most children meet the in a higher place criteria and are ready to exist toilet trained between 24 and thirty months of age.16,18
BEHAVIORAL
The most of import areas of behavioral assessment of toileting include ruling out the presence of disruptive beliefs problems such equally aggression, oppositional behavior, noncompliance and temper tantrums, establishing the child's compliance with adult instructions and obtaining a daily diary of toileting habits.
Coexisting behavior problems are a predictor of poor outcome in toilet-training protocols.xix Confusing behavior and babyhood noncompliance across multiple settings (eastward.g., dressing, bathroom time, bedtime) crave direct attention before toilet training is attempted. It is critical that the kid be cooperative and compliant with adult instructions; the kid should exist able to consistently follow at least 7 of 10 parental instructions in a timely manner.
Rather than relying on a parental report, the physician can only discover the child during an office visit to run across if the kid complies with parental instructions. Although protocols are bachelor for helping parents decrease a kid'southward oppositional behavior and increase compliance with instructions,20,21 many physicians choose to refer the child to a behavioral psychologist with experience in this area.
Finally, an important component of the behavioral assessment is pretreatment data on daily toileting patterns. A daily toileting diary provides a wealth of information that tin be incorporated into the handling plan (encounter accompanying patient information handout). For instance, the diary may help identify times to schedule toilet sits. Continued use of the diary may provide clues regarding treatment compliance and the effectiveness of the intervention.
Guideline two: Address Toilet Refusal Behavior
- Abstract
- Guideline 1: Place Potential Medical, Developmental or Behavioral Pathology
- Guideline 2: Address Toilet Refusal Behavior
- Guideline three: Ensure Soft, Well-Formed Stools
- Guideline 4: Schedule Prompted Toilet Sits
- Guideline 5: Provide Incentives for Appropriate Bowel Movements and Cocky-Initiation
- Guideline 6: Arrange for Physician Contact in Instance of Stool Withholding
- Illustrative Instance
- References
Many children with fecal soiling accept a history of painful defecation, toilet "phobia" or toilet refusal behavior.22 Positive toilet sits are one strategy to assistance children overcome negative associations regarding the bathroom. The goal of positive toilet sits is to associate the bathroom and the toilet with enjoyable activities and parent-child interactions. Initially, sits tin be scheduled three to 5 times daily at the family'due south convenience. The strategy starts with very short sits (eastward.g., 30 seconds) that gradually increase to a maximum of 5 minutes each, using a portable timer to signal completion. The child can remain in underpants or diapers because there is no expectation of producing a bowel movement. While the child is sitting on the toilet, proper foot support, access to enjoyable (relaxing and noncompetitive) activities and individual parental attention should exist ensured.
If a child is extremely resistant to approaching the toilet or potty chair, the parent may employ a gradual shaping process. For example, a parent begins by modeling appropriate toileting behavior for a few weeks; after this, the parent starts playing games or reading books with the child in or nigh the bathroom. The parent and child gradually progress to engaging in these activities while the kid is sitting on the potty chair for longer periods of time. During the modeling process, nosotros recommend that fathers and male person caretakers sit during urination. Boys should be encouraged to sit down while urinating until they are fully bowel trained.
Guideline 3: Ensure Soft, Well-Formed Stools
- Abstruse
- Guideline 1: Identify Potential Medical, Developmental or Behavioral Pathology
- Guideline two: Address Toilet Refusal Behavior
- Guideline 3: Ensure Soft, Well-Formed Stools
- Guideline 4: Schedule Prompted Toilet Sits
- Guideline 5: Provide Incentives for Appropriate Bowel Movements and Self-Initiation
- Guideline six: Arrange for Physician Contact in Case of Stool Withholding
- Illustrative Case
- References
Information technology is disquisitional to ensure that the child is having relatively frequent, soft and well-formed bowel movements before engaging in any intervention for soiling. Dietary changes or short-term apply of supplements such equally flavored fiber drinks or bran sprinkles may be needed to increase the number of bowel movements and to maximize daily toileting opportunities.
If obtaining frequent, soft and well-formed bowel movements continues to be a problem, the addition of stool softeners or laxatives may exist considered. Suitable daily regimens include Milk of Magnesia, in a dosage of 1 to 3 mL per kg per day; mineral oil, in a dosage of i to 5 mL per kg per day; or sorbitol, in a dosage of ane to 3 mL per kg per 24-hour interval. These agents can exist given in ane or 2 doses per solar day. Mineral oil is non indicated in children who are at risk for aspiration.13–xv
Any of these supplements may brand it more than difficult for the child to withhold bowel movements, resulting in more soiling accidents. Consequently, it is a skilful thought for parents to develop a standard clean-up procedure that tin can be carried out in a matter-of-fact, emotionally neutral way. The appropriate reaction is for parents to utilize a neutral tone of voice while directing the child through developmentally appropriate clean-up activities. Parents should avoid blaming, criticizing or name-calling during this time.
Guideline 4: Schedule Prompted Toilet Sits
- Abstract
- Guideline one: Place Potential Medical, Developmental or Behavioral Pathology
- Guideline 2: Address Toilet Refusal Behavior
- Guideline 3: Ensure Soft, Well-Formed Stools
- Guideline 4: Schedule Prompted Toilet Sits
- Guideline 5: Provide Incentives for Advisable Bowel Movements and Self-Initiation
- Guideline vi: Arrange for Dr. Contact in Case of Stool Withholding
- Illustrative Example
- References
When the kid is no longer resistant to sitting on the toilet and is having normal bowel movements, it is time to begin prompted toilet sits during times when the child is likely to defecate. These sits tin can be scheduled up to 5 times daily for three to v minutes each. The portable timer, which previously signaled the terminate of positive sits, at present terminates the end of each prompted sit down. The best time to schedule prompted sits is five to 20 minutes after each meal—to take reward of the gastrocolic reflex. Additional sits tin be scheduled during high-frequency opportunities as indicated by the daily toileting diary. From the child's perspective, these prompted sits will appear to exist no different than the earlier positive sits, as foot back up, toys, activities and individual attention are nonetheless available. The child'due south beliefs has merely been shaped to the point where he or she tin at present sit on the toilet without pants or diapers, in a pleasant and relaxed atmosphere, during a time when he or she is likely to defecate.
In one case this guideline is satisfied, the family is ready to concord a "graduation ceremony." This ceremony involves having a minor political party and informing the child that he or she is now a "large boy" (or girl) and that diapers will no longer be used. Information technology is of import that parents do not use diapers occasionally during the day (e.k., on a shopping trip) considering that sends a mixed message to the child about toileting expectations.
Guideline 5: Provide Incentives for Appropriate Bowel Movements and Self-Initiation
- Abstract
- Guideline 1: Place Potential Medical, Developmental or Behavioral Pathology
- Guideline 2: Address Toilet Refusal Behavior
- Guideline three: Ensure Soft, Well-Formed Stools
- Guideline 4: Schedule Prompted Toilet Sits
- Guideline 5: Provide Incentives for Appropriate Bowel Movements and Self-Initiation
- Guideline 6: Conform for Physician Contact in Case of Stool Withholding
- Illustrative Instance
- References
Although some authors recommend using incentives to target make clean pants or diapers,23,24 this practice may encourage fecal withholding and increase the hazard of constipation. Incentives can instead exist tied to the passage of fecal textile in the toilet. Incentives volition be virtually effective if they are age-advisable, given immediately after the desired behavior is displayed and provided after every occurrence of the behavior during the early phases of teaching.
Many types of incentive programs tin be developed, depending on the age of the kid, including access to processed, star charts, dot-to-dot pictures, grab numberless and special privileges or activities with parents and peers. Selected incentives should be fabricated available just subsequently advisable toileting, and access to these incentives should be restricted at other times.
When the kid is eliminating in the toilet and no longer having daily soiling accidents, self-initiation skills tin can be targeted. Parents will desire to gradually reduce verbal prompts to use the toilet, train the child to recognize the need to urinate or defecate and teach the child to request to apply the bathroom each time. Incentives are at present provided any time the child requests access to the bath and produces a bowel movement. Immature children should inform the parent or caregiver before using the bath to ensure proper monitoring and hygiene.
Guideline vi: Accommodate for Physician Contact in Case of Stool Withholding
- Abstract
- Guideline 1: Place Potential Medical, Developmental or Behavioral Pathology
- Guideline two: Address Toilet Refusal Behavior
- Guideline 3: Ensure Soft, Well-Formed Stools
- Guideline 4: Schedule Prompted Toilet Sits
- Guideline 5: Provide Incentives for Appropriate Bowel Movements and Self-Initiation
- Guideline 6: Arrange for Physician Contact in Case of Stool Withholding
- Illustrative Instance
- References
Although ensuring frequent, soft and well-formed bowel movements should reduce the likelihood of a child withholding fecal material, a dorsum-upward programme is necessary. For example, the family could be asked to contact the dr. if the child withholds for four consecutive days. A daily regimen of dietary supplements or stool softeners, as outlined in Guideline 3, may be all that is needed. If stool withholding leads to impaction, the doc may suggest hypertonic phosphate enemas (one to two per day, for up to three days) or suppositories, both of which piece of work efficiently.14 If parents prefer an oral plan, the dr. may use electrolyte solutions or high-dose mineral oil, in a dosage of 15 to 30 mL per twelvemonth of historic period per day (maximum: 8 oz). Electrolyte solutions often require inpatient access and nasogastric tubes to administer the volume and rate needed for effective evacuation. Mineral oil commonly takes longer to work than enemas and may result in increased soiling, cramping and intestinal pain until the fecal mass is passed.25 Once the kid is no longer impacted, the physician tin return to the daily regimen.
The post-obit illustrative example demonstrates the efficacy of these treatment guidelines in a kid with nonretentive encopresis and toileting refusal.
Illustrative Example
- Abstruse
- Guideline 1: Place Potential Medical, Developmental or Behavioral Pathology
- Guideline 2: Address Toilet Refusal Behavior
- Guideline three: Ensure Soft, Well-Formed Stools
- Guideline 4: Schedule Prompted Toilet Sits
- Guideline 5: Provide Incentives for Appropriate Bowel Movements and Self-Initiation
- Guideline vi: Arrange for Physician Contact in Case of Stool Withholding
- Illustrative Case
- References
A good for you 4-year-one-time boy whose developmental and behavioral histories were unremarkable was brought to the physician because of a 16-calendar month resistance to bowel training. He was generally cooperative with adult requests, exhibited age-appropriate social skills and rarely engaged in temper tantrums or aggressive behavior.
His foster mother reported that he had accomplished daytime bladder training past iii years of age, when he began wearing ordinary underpants. He used an adult-sized toilet and stood during urination; yet, he had never produced a bowel movement in the toilet. When he needed to defecate, he brought a diaper to his foster mother, stood in front of her and said, "I go poop." Within half hour of being diapered, he would usually walk behind the living room burrow to defecate into the diaper. Immediately afterwards defecation, he would return to his foster mother, who would remove the diaper, clean him and put him back into ordinary underpants. The child would defecate just while at abode in the living room and only when diapered. In the consequence of a family outing, arrangements were made to return home to provide him the opportunity to defecate. On occasions when he was refused a diaper, he repeatedly requested a diaper and withheld defecation for up to three days.
A complete history and physical examination revealed no meaning medical findings or evidence of fecal impaction. Behavioral assessment included a cursory clinical interview, beliefs rating scales and a toileting diary that the foster mother maintained throughout assessment and intervention.
The child was placed on a daily fiber supplement to ensure frequent bowel movements and to reduce the likelihood of fecal withholding. The foster mother agreed to contact the physician if the kid had not defecated for four days. A plan of positive toilet sits was begun, using preferred toys while the foster mother actively engaged him in play and chat. A kitchen timer was used to indicate the stop of his "bath fun."
Information technology was reported that he "accidentally" produced his start bowel movement in the toilet during a positive sit. Although he appeared fearful at first, his foster mother reassured him through concrete affection, verbal praise and a modest reward. By the seventh day, the boy willingly sat on the toilet and was enjoying bathroom activities. During the second week, family and adult friends held a "graduation anniversary," during which his diapers were symbolically thrown away.
For several days after his graduation, the child repeatedly asked for a diaper. These requests were ignored and the fiber supplements and prompted toilet sits were continued; notwithstanding, the child did not defecate for three consecutive days. The physician encouraged waiting one more than mean solar day before beginning oral mineral therapy. The adjacent twenty-four hours, the child defecated during 1 of his prompted toilet sits.
Over the next few weeks, he continued with the scheduled sits, fiber supplements and incentives for appropriate toileting while his foster mother monitored his toileting habits. By the 3rd week he was no longer soiling his pants and had begun to independently request to apply the bathroom. Consequently, the fiber supplements, prompted sits and incentives were gradually discontinued. During a vi-calendar month follow-up telephone contact, it was reported that he continued to toilet independently with no soiling accidents (Figure 1).
Illustrative Case
FIGURE ane.
Frequency of soiling accidents and bowel movements in toilet and pants across baseline and intervention in the patient in the illustrative instance.
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REFERENCES
show all references
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2. Doleys DM. Enuresis and encopresis. In: Ollendick Thursday, Hersen Chiliad, eds. Handbook of kid psychopathology. New York: Plenum, 1983:201–six.
3. Walker CE, Shaw W. Assessment of eating and emptying disorders. In: Karoly P, ed. Handbook of child health assessment: biopsychosocial perspectives. New York: Wiley, 1988;434–69.
4. Christophersen ER, Rapoff MA. Toileting bug in children. In: Walker CE, Roberts MC, eds. Handbook of clinical kid psychology. second ed. New York: Wiley, 1992;399–411.
5. Levine MD. Encopresis: its potentiation, evaluation, and alleviation. Pediatr Clin North Am. 1982;29:315–30.
half-dozen. O'Brien S, Ross LV, Christophersen ER. Primary encopresis: evaluation and treatment. J Appl Behav Anal. 1986;xix:137–45.
7. Levine Doctor. Disordered processes of elimination. In: Levine Doctor, Carey WB, Crocker Ac, eds. Developmental-behavioral pediatrics. Philadelphia: Saunders, 1983;586–95.
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9. Blum NJ, Taubman B, Osborne ML. Behavioral characteristics of children with stool toileting refusal. Pediatrics. 1997;99:50–3.
10. Taubman B. Toilet training and toileting refusal for stool only: a prospective study. Pediatrics. 1997;99:54–8.
11. Luxem MC, Christophersen ER, Purvis PC, Baer DM. Behavioral-medical treatment of pediatric toileting refusal. J Dev Behav Pediatr. 1997;18:34–41.
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13. Schmitt BD. Encopresis. Prim Intendance. 1984;11:497–511.
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16. Christophersen ER. Toileting problems in children. Pediatr Ann. 1991;xx:240–4.
17. Luxem Yard, Christophersen E. Behavioral toilet training in early childhood: research, practice, and implications. J Dev Behav Pediatr. 1994;15:370–viii.
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25. Gleghorn EE, Heyman MB, Rudolph CD. No-enema therapy for idiopathic constipation and encopresis. Clin Pediatr. 1991;30:669–72.
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