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Monday, October 20, 2014
Bowel Movements in Pants
Need information on how to deal with a five year old who is having bowel movements in his pants all the time. It is not an occasional accident...almost seems more defiant or deliberate. Comments/suggestions?
This is not an uncommon problem, but it is frustrating for both the child and parents. I cannot tell from your question whether you are the parent, but their involvement is crucial to solving this dilemma.
Evaluation must include a full visit to the pediatrician or practitioner, and includes a history of development, toilet training and stooling habits, diet and fiber intake, disciplinary issues, stressors, and practical issues, such as the availability and appropriateness of the facilities the child must to have a bowel movement. If the child is only having a problem in one domain of his life, that should be investigated further.
The physical exam must include assessment of the degree of constipation involved, rectal function, and growth and developmental assessment, as well as a general exam.
Unless there are emotional stressors that are being left unattended, including humilation or undue force/character of punishment, this is generally not a control issue. It is a common mistake for adults to make it one. It is obviously a sign that the child does not have positive coping skills in that setting, and this needs to be addressed. A five year old with age appropriate development can be shown to take responsibility for toiletting, and the adults must remove punishment for soiling. This problem creates enough social ostracism on its own. Generally, if the physical exam is normal, we encourage parents to include plenty of fiber in the diet, ensure that constipation is dealt with, give the child a toiletting schedule (generally three times a day, after meals, for 5 to 10 minutes), perhaps with a star chart for positive reenforcement, and find a reward system which the child will respond to. Then it is up to the child to take responsibility and stool in the toilet. As a general rule, punishment for this behavior is not only counterproductive, but may encourage more "accidents". The child needs to receive attention for not stooling in his pants, not the other way around.
If this is a long standing problem, the emotional repercussions (especially if it has been happening at school) may already be causing the child problems, and use of behavior therapy may be very valuable. It is not uncommon for these children to have very low self esteem. Biofeedback may also be helpful, and when these interventions are needed, we will often have the child see a gastroenterology specialist.
In summary, a full medical assessment is needed, with a plan of action that gives the child positive reasons to avoid accidents, and addresses physical concerns which may be preventing him from success.
Caroline Mueller, MD
College of Medicine
University of Cincinnati