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Expert Q&A

	By Paul Coleman Psychologist Family Therapist

My 5-year-old niece will have bowel movements in her pants, but not in the toilet. Her parents recently divorced. Could this be psychological?

The technical name for the problem you are describing is encopresis. To be formally diagnosed, the child must be at least 4 years old and experience fecal incontinence for at least once a month for three consecutive months. Also, incontinence should not be due to a medical disorder other than constipation.

The problem is typically involuntary but it can be intentional. Often, the problem develops after that the child is constipated, becomes impacted, and then experiences an overflow. The constipation can develop for emotional reasons such as fear of using certain bathrooms or due to anger and oppositionalism. Or the constipation could be due to medical reasons. Chronic constipation can make bowel movements so painful that the child avoids them until at some moment he loses control of the situation.

First, don't rule out some medical component to the problem. Hypothyroidism can be a cause. Some children have a flaccid anal sphincter muscle. When constipation is part of the problem, careful use of laxatives may be necessary. Please consult a physician. If the child is not constipated, the child is probably showing some kind of defiance.

The fact that his parents divorced two years ago may be a factor, though encopresis is not a typical response to that situation. (About 1 percent of 5-year-old children are diagnosed with encopresis.) I would certainly want to know what the parents have done so far to correct the problem. I gather from your question that the child has never been toilet trained. That being the case, treatment may be somewhat more difficult than it would be if he had been properly trained and only recently showed signs of regression.

First, the child should be examined by a physician. Second, at least one -- if not both -- parents should consult with a child psychologist. Usually, it is a matter of devising a system of rewards for the child. For example, if he really enjoys playing video games, he would have to earn video-time by proper use of the toilet. A psychologist can help determine if the child has additional issues such as anger and defiance over the divorce.

The parents, and you as the caring relative, might find the book How to Say It to Your Kids useful. It discusses a unique and helpful approach to communicating with children and gives concrete examples of what to say and what not to say for 100 situations such as divorce, bedwetting, anger management, and so forth."

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