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Foreword I

A Pediatric Gastroenterologist’s Insights on Soiling Solutions®
By Audrey H. Birnbaum, MD Mount Kisco, NY

It’s 9AM and I walk into my exam room finding a shy, cute 7 year old boy sitting on the exam table. His mother is there with him, but there is a third presence in the room also -- the distinct, unmistakable odor of old feces. I know right away this boy is here to see me for encopresis (fecal soiling), but when I look on my intake sheet for the reason for the visit, his mother has only vaguely written “bowel problems.” I would venture to say that many of my Pediatric GI colleagues would not find this to be the high point of their day, but it doesn’t bother me at all. Besides being relatively “immune” to the scent of stool after over 20 years in practice, I actually relish the opportunity to help this child - because I already know his parents are extremely worried (and may have at one point been angry), I know he is quite ashamed, and there is a very good chance he has never been treated, or never properly treated for this condition. Lacking any proper humility, I boldly tell his mother that this is an entirely fixable problem that we should be able to resolve within weeks to months. And this is actually true. The question at hand is how to successfully achieve that goal. Is it a fixable problem? Absolutely. No child has to go to school smelling of feces. And no parent or physician should give up treatment because the prescribed treatment has not worked and they do not have anything else to offer. The standard of care in Pediatric Gastroenterology is very often successful. It is predicated on the following principles: stool retention fills the colon (large intestine) making it flaccid and poorly functioning; an overfilled colon will lead to “leakage” due to “overflow;” a chronically filled rectum loses sensation of the urge to defecate; and keeping the bowels moving through artificial means will allow these processes to return to a normal state over a period of time. Not surprisingly then, treatment is aimed at each of these “malfunctions.” If the colon is first emptied, it will no longer be full of stool and the accidents should immediately cease. However, since the colon is still widened and flaccid, it must be kept emptied through the use of some type of laxative or stool softener. Okay, that makes sense too. Over a period of time, the colon and rectum should shrink and rectal sensation should return and … Voila! Problem solved!!!! Well, I would venture to say that this method does often work. And when I have seen failures, sometimes it is just a matter of an inadequate first step (the clean-out), or a poor choice of the second step (the laxative part), such as using a stool softener that make the stool too liquid and doesn’t provide an “urge” to defecate. But here is where we physicians fail miserably….What happens when we don’t achieve success? What do we recommend then? v

I have heard some very disappointing stories at this point. Families are often “dismissed” from the practice or told there is nothing more that the doctor can do. They may be sent for another opinion but it is really not for advice, but as a way of having the patient go away. They may be told to keep giving the laxatives or stool softeners despite constant soiling and to just wait for the child to outgrow the problem. Or they may be sent for psychotherapy to see if there is “something behavioral going on.” Well, I can’t say I did much better. Until recently, I had no other avenue, no other place to turn for children whom I failed. Repeat cleanouts, trying different laxatives, behavior modification, were the only tools we gastroenterologists had. We have been taught NOTHING else. Of course we might do further testing if a child was not doing well, but the likelihood of finding a true medical problem was exceptionally low. My turning point came when I was treating a patient whose mother was a colleague, a pediatrician whom I had known for many years. I was failing this child miserably and it was exceedingly embarrassing, to say the least. I felt a little vindicated when they moved to another state, went to a premiere Pediatric Gastroenterology program in Philadelphia, did a few tests (all negative) and also failed treatment. Frustrated but persistent, this mother found Soiling Solutions® on her own and within one or two weeks, her daughter’s problems were resolved. Even after I found out that she had used the Soiling Solutions® program, I was still resistant to even looking it up on the Web, dismissing it summarily because it was not a physician-supported program. Skeptically, I gave in and eventually, realized that it made perfect sense, bought the manual, and was completely “sold” on the concept. It was SO OBVIOUS where the problem lay. It was in the withholding itself! Those children who still withheld stool would clearly not respond to any amount of laxative you could give them. Fooled by the fact that these children, who were not toddlers anymore, did not refuse to sit on the toilet, I did not “get” that they might still be subconscious withholders. No, we doctors didn’t have a treatment for withholding, and neither did the psychotherapists. The beauty of Soiling Solutions® from my perspective as a physician is that is the perfect bridge between the physical and the behavioral side of encopresis. It is the only program I know that addresses both issues simultaneously. While Dr. Collins is working on reconditioning responses, he is also making sure that the child is defecating adequately EVERY DAY. A child who is doing this is not soiling. He does not smell. And his colon is shrinking and not retaining stool. So the goals and principles I had stated above (from a physiologic standpoint) are being met, while he is relearning how to do all the things required to go to the bathroom normally. Since learning about the program, I have recommended it for numerous patients with universal success. My patients, some of whom struggled for years, have expressed tremendous gratitude, most of which I will redirect to Dr. Collins. Many of my patients have seen success within a matter of just a few weeks, even if they vi

have struggled for years with encopresis. Some of the patients have been teenagers involved in years of psychotherapy. No, I have not given up my standard treatment, which I believe still has its place. But Soiling Solutions® undoubtedly is a valid and extremely important treatment option for encopresis. Finally, I would like to add that I have absolutely NO financial interest in Soiling Solutions®, so everything you may read here is an honest, from the heart, account. Those of you who are reading this most likely are already on your way to success, so to you, I say, congratulations for getting here! Audrey Birnbaum, MD Mount Kisco Medical Group Mount Kisco, NY

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FOREWORD-II
A Mother and Clinical Social Worker’s Insights on Soiling Solutions®
By Eunice Lehmacher, LISW-CP Seneca, SC

None of us would have picked encopresis as a disease for our children. But now that I have gotten through it (with the help of Soiling Solutions®), I can see that our family and I benefited in many ways. I now have a child who likes eating salads and has a well-balanced diet (and is probably less likely to be obese or get heart disease). All of us appreciate our natural processes more, and our family has learned and practiced many ways to relax. We all learned that sometimes our schedules and priorities need to shift for another family member’s needs. My parenting skills have grown (e.g., I am more consistent, I am better at being firm, but loving. I am not so easily manipulated. I have gotten to be quite good at behavioral training). My son has learned that I love him no matter what (come pee or poopy undies). I have read that enco kids are strong willed, and this certainly fits my son. I am glad to have gone through this battle of the wills young. He has learned that I will follow through no matter what and that when I do its part of my unconditional love for him. And, he has even learned that he is better off because of it. Although I am not the mom of a teenager yet, I suspect the battle of the wills would have been nastier when he is 17 years old. I cannot say that I am happy about all that time I spent in the bathroom and with the dirty laundry. But from a perspective of three years clean with most of the bad memories faded, I can say that I am glad to have this 11 year old who has come through this crisis and is better for it. He no longer even needs reminders to poo. I have also learned that when I have a problem (even if it is an embarrassing problem), it is better for me to be open about it instead of being ashamed and secretive. The internet Soiling Solutions® forum provided me with a community who understood our problem and was encouraging. This process taught me that when I have the courage to talk about my problems, help comes. Being open about enco helped me to be open about other problems later, and to be more accepting of myself and my parenting. At the beginning of this process, you are not ready to think of encopresis as something good that happened to your family. But perhaps in two weeks, two months, or two years, you will realize that you and your child have grown immeasurably through this behavioral training. You will not enjoy all parts of the journey, but you will not regret doing Soiling Solutions®. Dr. Collins' approach works for the poo and the development of your child. And as a nice bonus it will grow and support you as you parent. I will “see” you soon on the forum.

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CKMV-2nd Printing on Eliminative Disorders

Chapter 1

Old and New Views

Chapter 1 OLD AND NEW VIEWS ON ELIMINATIVE DISORDERS
Encopresis The Clean Kid Manual© (CKM) is a specialized how to manual for treating encopresis and enuresis. It is available only from the Soiling Solutions®1 store at the www.encopresis.com website. Encopresis is a disorder of bowel control marked by at least once a month soilings for at least three consecutive months in children aged four years and older, according to the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-R), or the same for six months according to the International Classification of Diseases-10th Revision (ICD-10). Insurance companies will require one or the other coding system for payment. In addition, organic factors or a disease basis must be ruled out by a physician. Rule outs occur in only about five percent of cases of soiling. Thus, encopresis is a functional medical disorder. It affects two to four percent of children. The medical specialist for dealing with encopresis, if needed, is the Pediatric Gastroenterologist or a Colorectal Surgeon. A condition closely related to encopresis is enuresis, which is another eliminative disorder. It is a bladder disorder of daytime wetting (diurnal enuresis) or bedwetting (nocturnal enuresis) in children five years and older. It is also regarded as a functional medical disorder once physical reasons are ruled out. It affects about 10-15 percent of children (mostly as bedwetting). If day or night wetting is present it should be addressed only after bowel control is achieved. An overly full colon adds to abdominal pressure and pelvic floor tension which destabilizes bladder function. Enuresis will be addressed later in
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Enuresis

Soiling Solutions is a “doing business as” (dba) name registered with the State of Michigan for the professional corporation, Robert W. Collins, PhD, PC. I, Robert Collins, am its employee, president, and the author of its website and manuals. I will speak as an author and employee for the corporation throughout this manual. All policies in this manual may be subject to change. Updated policies may be found on the main Soiling ® Solutions website at www.encopresis.com.

®

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chapters 7 and 8 of this manual. The earlier chapters will be devoted to encopresis. The medical specialist for children’s bladder problems is a Pediatric Urologist. Functional Disorders Functional disorders can frustrate physicians and parents. We are familiar with the disease or medical model which has proved to be very effective in treating all manner of problems by treating a physical cause. When physicians offer a simple biomechanical treatment of oral stool softeners or laxatives to drain the colon it makes physical sense, but if accidents continue or learning to go on the toilet fails, everyone will want to look deeper. Assurances that the child will grow out of it will begin to sound empty if fecal accidents persist for a year or longer. Waiting for the Continence Fairy is not a viable strategy. This explains why parents often find themselves in a kind of twilight zone debating a psychological or medical basis as an origin for their child’s problem! Parents will frequently express what appear to be psychological issues.
“Why doesn’t he feel the accident?” “How come he ignores such a smell when it is so obvious to everyone else?” “Why does he fight me about sitting on the toilet?” “Why is he hiding his soiled clothing?” “I know he knows about bowel movements and he has to take responsibility for it, but he just won’t and completely denies having to go and sit on the toilet.” “I see him in the oddest postures and it is clear that he is desperately “holding” and fighting having a bowel movement.” “It is so obvious to me and everyone else that it is easy to sit and go when we feel voiding urges.” “He is very smart, but just does not appear to get it.” “He is just plain stubborn.”

Psychological or Medical or…?

It is almost as if these just cited instances could be about a messy bedroom and why doesn’t the child keep it clean and orderly? One thing is certain, we can tolerate messy bedrooms, even wet sheets, but anything involving feces is much more intensely provoking and distressing. The degree of emotional conflict, the contest of wills, is all magnified when it involves this foul, smelly, diseasebearing body product. It is nothing like “Wash your hands.” Or, “Brush your teeth.” Or, “Clean your room.” This failure of bowel control has very high stakes for the 2

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Old and New Views

role of a parent. The whole family is affected. It can contribute to divorce. The Twilight Zone I am a doctoral level Clinical Psychologist, not a physician. However, I have published in both the medical and the psychological literature. I have a lot of sympathy for parents, physicians, and psychologists alike who find themselves in the twilight zone. The field I work in is called Behavioral Medicine. It brings light to this mysterious zone and offers more effective approaches to these frustrating conditions. Encopresis involves higher level brain functions. It has a behavioral and a physical expression. Focusing on the gastrointestinal tract alone is misleading. My research has examined the brain mechanisms involved in bladder and bowel elimination. My professional career got off to a good start by validating the most effective treatment for nocturnal enuresis2, the bedwetting alarm. This research brought me a lot of professional recognition and a nine month long invitation to the University of Western Australia in Perth, Australia. This is when I began to turn my attention to encopresis which is experienced as much more distressing by the parent and child. Encopresis is ill-tolerated by other children, schools, and parents. It is socially isolating and everyone is distressed when it appears to resist the standard medical approaches treatment. It cannot be ignored! It has both long term emotional and physical consequences. Fortunately, early recognition and the Soiling Solutions® treatment protocol with the help of the Soiling Solutions® Parents’ Forum can head off these complications. The predominate top down oral stool softeners are Miralax (which is Polyethylene Glycol, PEG, PEG-3350, or Movicol), Lactulose (a synthetic, non-digestible sugar), Colace (docusate sodium), Milk of Magnesia (Magnesium Hydroxide or MOM), Magnesium Citrate, or a Mineral Oil emulsion (e.g., Kondremul). Miralax has become the preferred stool softener by far with physicians. These

From Bedwetting to Encopresis

Encopresis Tolerance?

Stool Softeners

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Collins, R.W. (1973). Importance of the bladder-cue buzzer contingency in the conditioning treatment for enuresis. Journal of Abnormal Psychology, 82(2), 299-308.

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oral agents make the stools easier to pass.3 They are thought to reduce the likelihood of pain and toileting resistance. Laxatives Laxatives are different from stool softeners. They activate or stimulate the gastrointestinal tract directly to produce contractions to speed up the foodstuff waste down the colon. Typically, bowel movements result with sits some 6-10 hours later. Products containing Senna (e.g., Ex-Lax, Senekot) or bisacodyl are off the shelf examples of laxatives. Pericolace contains both Senna and Colace, a combined laxative and stool softener. Parents often obsess over fiber intake and diet restriction (e.g., dairy, gluten, etc.) as potential factors affecting gastrointestinal tract activity. Probably the most significant and often overlooked factor for parents is to encourage adequate fluid intake regardless of diet. Probiotics are receiving more attention and becoming more available. Soiling Solutions® with a bottom up approach allows a clearer, daily look at fuller more natural stool production so that the effects of diet can be better judged over time. Generally, the purpose of the top down approach is to achieve apple sauce quality stools with softening agents alone and to have the child sit for 10 minute periods after meals to encourage a bowel movement. The use of behavioral charts with reinforcing consequences is often advised. This approach works in up to 60 percent of cases within a year, but only approaches 80 percent after eight years!4 I find it interesting that the medical community has called this approach maintenance therapy. In some sense it is not so much regarded as a treatment for halting the disorder as much as it is intended to prevent serious medical complications like blockage or a ruptured colon. If the child leaks or oozes stool, well, no big deal!

Diet and Allergy Concerns

The Old Apple Sauce Approach

3

Brand names are mentioned throughout this manual for ease of recognition. I have no financial interest in any of these brands. Generic and often cheaper versions are usually stocked next to these major well-recognized and advertised brands. Movicol is Miralax outside of the USA. 4 Van Ginkel,R., Reitsma, J.B., Buler, H.A., Van Wijk, M.P., Taminiau, J.M., & Benninga, M.A. (2003). Childhood constipation: Longitudinal follow-up beyond puberty. Gastroenterology, 125(2), 357-363.

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Old and New Views

At least he5 is safe and you are avoiding physical complications -- or are you? Beyond Apple Sauce? My observations suggest that the top down approach may actually train more holding because of fear of accidents and negative parental and peer reactions. The Soiling Solutions® protocol absolutely assures daily, more complete elimination. Soiling is quickly arrested within two weeks for the majority of children. The problem with very soft stool is that the colorectal sampling mechanism, which includes brain recognition, has trouble recognizing it. For example, it is difficult to distinguish it from gas. You likely have experienced this yourself with diarrhea. Also, when a child gets backed up with soft stool and he runs, jumps, changes posture, coughs, sneezes, laughs, giggles he is much more likely to lose control of it. The colorectal pressure becomes too high from holding making accidents more likely. Initially, children are alarmed at accidents, poop squirts, or oozes and often redouble their efforts at control by excessive holding or hiding their failure. This is extremely frustrating for you and for them. Repeated failure is to be denied and hidden with a brave front or depressed withdrawal. Some children will be angry and aggressive along with denial. The chances are that you have become a part of this vicious cycle and you will have to learn to forgive yourself. The sooner you catch on to what has been happening and properly address it, the sooner you and your child will recover your real parentchild relationship. You will be seen as wise and heroic for taking effective action however difficult it may be. Indeed, the war is really on sneaky poo itself. There is a book with that title on the internet. The idea is that, instead of fighting or struggling with and blaming one another, you become allies in fighting this common enemy that you both hate. Other books are available on the internet that helps the child to desensitize and view poop as more normal, e.g., Everyone Poops. However valuable these sources are, they really do not provide actual solutions.
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Added Accident Risk

A Vicious Cycle

Sneaky Poo and Everyone Poops

The masculine pronoun will be used throughout the rest of this manual.

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CKMV-2nd Printing on Eliminative Disorders Soft vs. Brutal, Really?

Chapter 1

Old and New Views

I do not agree with continuing the top down approach with stool softeners after it has had a reasonable trial for up to a year. Its many, many advocates have even called it the soft or gentle approach and actually induced guilt and avoidance among physicians and parents for considering suppositories and enemas. I’ve had physicians command parents, Don’t touch his butt! And, it can work both ways: one physician was intimidated by a parent calling him a Poop Nazi for suggesting an enema! Believe it or not, doctors can be intimidated. You will find the children resisting going into the bathroom and sitting for long enforced periods. Many mothers turn the bathroom into entertainment centers to encourage time on the toilet. Children do not understand time well; any sit requirement however short is forever or an eternity to them! Kids live in Now Land! Add ADHD and you have real problems! Soiling Solutions® will show you how to have your child live in and tolerate real time. When the soft approach fails, some physicians will say “He’ll outgrow it” instead of finding alternative treatments that do work. This latter approach is an appeal to do nothing! Advocating a passive or very passive approach fails to understand the urgency that parents have to overcome this problem. A more direct and active intervention is required. Here is where parental responsibility has to come to the fore. I have come to view the formation of an adequate voiding habit as an emergency priority for these children and parents when the top down approach fails. The Soiling Solutions® protocol can stop soiling for 90% of children within two weeks. Waiting is not a solution. It has its own damaging emotional and physical consequences. Children hold, hold, and hold some more. They hold out of fear and they have voiding accidents with fear. Holding is becoming more deeply installed! They fear anything coming out and they sure do not want anything to go in down there! They and you have taken the culture’s message to heart! This is a real double whammy. You and they cannot win! Encopresis may actually become more resistant to change. What a vicious cycle! You have been caught up in it! THIS IS NOT YOUR FAULT. Let the guilt go, please! 6

Now Land

Passive vs. Active Approaches

The Double Whammy

CKMV-2nd Printing on Eliminative Disorders The Triple Whammy

Chapter 1

Old and New Views

The addition of pediatric warnings to resist the bottom up training approach and your fear is a kind of triple whammy! Our cultural fears about sexual abuse, trauma, and inhibitions in dealing with this very private sexual area of our bodies play a large role in resistance to the Soiling Solutions® protocol. The power of the Soiling Solutions® protocol is that it can all be done in the home by firm and loving parents thereby mitigating these very powerful fears. I do not see trauma in kids if the parents maintain their course. If insulin shots or eye drops are required, which raise very natural fears, the parent somehow will overcome the fears in the best interests of their children. Children will detect any fear and ambivalence on your part and react to it. They may manipulate you or their anxiety may be fed by your anxiety. Nonetheless, in a week or two, the children begin to realize that they feel better and are happier with no accidents. The human forebrain matures very, very slowly, and we continue to see a lot of poor judgment in teenagers and young adults. I have seen traumas result when medical personnel have to administer more powerful enemas, or if overnight hospitalization is required for a nasal drip to dissolve a severe blockage. This can create a fear of doctors and hospitals. This is not a good idea! Positive parenting in a loving home is best. I have become controversial in pointing out that the standard pediatric top down approaches should be abandoned after, at most, a one year trial. Training failure and more holding only assures continuing failure! What goes in must come out. Better guidelines are needed in pediatric practice! I see way too many older children coming to Soiling Solutions® as a last resort even into their teenage years. Failure is not a good option. Fortunately, even for older children, much of it can be reversed. Parents report dramatic psychological changes as their children recover from this debilitating disorder. Some have even noted growth spurts with improved appetites. The physical recovery of the colon can take considerably longer and the daily Soiling Solutions® treatment hour may have to be 7

The Trauma Question

Medical Trauma

Training for Failure?

Emotional and Physical Recovery?

CKMV-2nd Printing on Eliminative Disorders

Chapter 1

Old and New Views

applied for months or even years for some children. Fortunately, this is very rare and is addressed in a troubleshooting chapter later in this manual. What Is Really Missing? The missing critical element of the top down approach is that just sitting on the toilet cannot train how to change from holding to releasing stool. That transition from holding to releasing his stool on the toilet is a critical missing link in today’s approaches to encopresis. Holding is a natural initial response to voiding urges. It is hard-wired in our brains. This is called a reflex arc. Here it is: colorectal urge stimulus >>> brain recognition >>> colorectal (hold) response. This initial holding becomes overly powerful in encopresis. It will not give way to the voiding reflex arc in a timely manner when sitting on the toilet. For lack of a better term I will call this a brain lock. This is a habit. Habits can be good or bad. They are very resistant to change. The ability for us to go seems natural and easy, but not so for these children! Many parents observe that when the child is required to sit and go that he will stiffen his body and clench his butt in order to hold back his bowel movement. One mother described her child turning into a plank on the toilet. At other times the child can be observed standing on his toes, bending backwards, clenching his buttocks, stiffening his body, and sitting on his heels in obvious efforts to not have a bowel movement. The child gets so good at this it becomes automatic and habitual. One child actually told his mother when asked to sit, “Wait, wait, it will go back in!” It can be so overlearned that they are not even conscious of these holding efforts! Some children on the toilet stool may even turn red as they push in apparent efforts to eliminate when at the same time they are, reflexively, tightening their External Anal Sphincter (EAS)6
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The Plank Child

A dual sleeve of two different kinds of muscle tissue surrounds the anal opening. The EXTERNAL ANAL SPHINCTER (EAS-outside rim of the anal opening) is striated, voluntary muscle tissue, which can voluntarily or automatically contract to block the anal opening. The INTERNAL ANAL SPHINCTER (IAS) is involuntary smooth muscle, with a passive tension or tonus level that is sufficient to prevent leakage of normal stool under most instances as we go through our daily activities. Under ordinary circumstances the urge or signal to void will cause EAS contractions sufficient to hold back the stooling urges until they pass or we find a toilet to sit and relax the EAS so that the stool will overcome the little resistance offered by the IAS and a bowel movement results.

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and another muscle (the Levator Ani) to choke off a bowel movement. Parents may remain clueless about this battle! It looks like he is trying to push as his face turns red and, sadly, he truly may be trying! Vicious Cycle >> Virtuous Cycle This form of holding and failure to relax so as to release a bowel movement on a reliable basis is coming to be increasingly recognized and has been called dysnergia or dyscoordination of the proper muscles in the proper sequence. Other terms are anismus, dyschezia, outlet obstruction, or the Rectal Anal Inhibitory Reflex (RAIR). The bathroom sit for these children has become a stimulus to hold in what has become a vicious cycle. If this could be trained so that a bathroom sit results in a reliable transition to a release reflex arc or bowel movement you would have a virtuous cycle! Sometimes parents are delighted when their child asks for a pull up and he is able to have a bowel movement in it! Alas, the moment of truth has not yet arrived and at some later time a battle will ensue with requests to sit on the toilet to go. Literally, the toilet stool and the bathroom have become powerful holding cues. The pull-up or diaper has become a well-established release cue. In toilet training our cat to use the toilet stool I had to remove the litter box and loose rugs. Guess what the pull up or diapers are equivalent to here! We want the toilet stool sit to become the proper release cue to replace the diaper release cue. Pull ups cannot be worn forever and poo cannot be retained forever! The most common onset for encopresis is during ordinary toilet training. All kinds of factors come into play here such as parental demands, parenting styles, and attitudes. Oh yes, there is the child! They are NOT blank little tablets that we write on and program! They are striving for autonomy and have their own temperaments. They have learned the power of “NO,” “dun wanna,” and “ain’t gonna.” They bargain, they resist, they cry, they scream, they hide, they run away, they become a plank if you sit them on the toilet. Some will become fantastic future lawyers with their dramatic and verbal skills that pierce you to your heart or render you a blithering idiot.

Cats, Kids, and a Litter Box?

Causes, Causes, and More Causes!

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CKMV-2nd Printing on Eliminative Disorders School Holding

Chapter 1

Old and New Views

The second most likely onset of encopresis occurs with going to school where children tend to avoid the school lavatories and hold all day long. This may be made easier because the gastrointestinal tract slows down under the stress of school demands and activities (a so-called sympathetic nervous system dominant state). This can start up the holding habit and set up failure. When the child approaches the end of the school day and anticipates going home that is when the gastrointestinal tract is unleashed with a vengeance and accidents are most likely to occur. This is called a parasympathetic rebound effect. It is extremely powerful. When I mentioned this to parents I frequently saw a light bulb go off in their heads as they connected it to their child’s soiling. A condition similar to school can occur for children of divorce going between households. The dynamics of the parent-child interaction can lead to more holding in one household than the other. The child may develop a pattern of having soiling accidents in the household where they are more relaxed after returning from a household where they have been more stressed. This can lead to very unfair charges between alienated parents. Diaper manufacturers have become highly inventive and produce larger and better diapers and pull ups every day. This can delay training for many children today because of an over-worked single parent or two parents. The child forms the habit of going anywhere at any time with maximum convenience and may resist demands to leave the convenience of his pull ups behind. Diaper cleaning services can also make delaying training more acceptable. Delay may result in a developmental age where he is more stubborn and resistant to parental demands as he seeks more control and autonomy. Also, he is older, smarter and has gotten to know your weaknesses better! The toilet bowl can be scary and cold with its horrible sucking sounds upon flushing. Later, I will describe a device, a bidet insert, which can make the toilet more attractive for the whole family. The child may have become constipated because of diet, an allergy, or illness and had just one painful bowel movement that triggers encopresis. Even such apparent10

Divorce Holding

The Profit Motive?

The Toilet Bowl Suck Hole

Pain or Discomfort

CKMV-2nd Printing on Eliminative Disorders

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Old and New Views

ly minor changes as going camping and vacations can be occasions for initial back-ups, dried out stools, and painful bowel movements which can initiate and lock in holding. It just does not take much at all to cause months and years of emotional and physical distress Physical Consequences The colon, when stretched out, can become weakened and less effective in pushing the stool downward with sufficient force to abet having a bowel movement.7 Also, a stretched colon becomes less sensitive to recognizing fullness so that the child is more likely to be caught by surprise that he has to go. These children frequently can clog toilets. The consequence of an enlarged colon can cause more pressure on the bladder causing bladder accidents. Urinary tract infections (UTIs) may become more common, especially for girls, because their anal canal is much closer to the urethra than it is for boys. As noted earlier, holding is a prepotent or primary hardwired response to stool or colonic urges. It is normal. We all hold until we get to the proper place with privacy and let go. Diapers and pull ups when overused subvert this normal process. This letting go reflex is critical and has to be trained and made to be 100 percent reliable and automatic. It is that transition from the holding reflex arc (brain mediated) to the release reflex arc (also brain mediated) which is the rub! Once started encopresis takes on a life of its own. The original causes become irrelevant; maintaining causes take over. Will power, persuasion, blame, assigning responsibility, doing nothing, punishment, and rewards cannot succeed. It becomes a too deeply automatic and engrained habit. This is usually when parents seek out Soiling Solutions® and order the Clean Kid Manual. Upon my return from Australia in 1976 I began to apply my ideas on the use of suppositories and enemas in the private practice I had in Grand Rapids, MI. I reasoned
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Original Causes >> Maintaining Causes

The Idea From “Down Under!”

A well-done study out of Emma Children’s Hospital in Amsterdam, the Netherlands, shows that a stretched out colon may result in ineffective treatment by the top down approach. Even if the treatment is successful, you can have a continued weakened and stretched out colon some four years later. Van den Berg, M.M., Voskuijl, W.P. Boeckxstaens.G.E., Benninga, M.A. (2008) Rectal compliance and rectal sensation in constipated adolescents, recovered adolescents and healthy volunteers. GUT. 57(5), 599-603.

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Old and New Views

that a daily adequate evacuation of stool while sitting on the toilet would encourage the correct connections and assure prevention of a backing up and more dried up hardened stool. Fresh and more normal hot dog stools would be available the next day. This would make stool softeners less necessary. I was astonished at the excellent results. I fine-tuned the results to assure that the children acquired total control without dependence on artificial agents. The first edition of the Clean Kid Manual (CKM) was written in 1998 when I recognized that a reliable and effective home-based treatment could be more readily and widely disseminated with the emerging dominance of the internet. I sought to further spread the protocol with professional publications in hopes that the professionals would research it and make it more available to their patients. A History and Rationale for ® Soiling Solutions My medical journal article, Soiling Solutions®: An Internet and Manual Based Approach to Treating Encopresis was published by the International Foundation of Functional Gastrointestinal Disorders (www.iffgd.org). It is available in Appendix 1 of this manual and on my encopresis website. Appendix 1 and the website also contains a letter to your physician. It may be helpful to recruit your physician to at least be available and to monitor you. You may copy both of these items for him or her to review. My approach is radical! It is not for the faint-hearted! It requires parents to be, well, parental! It is a stepped approach of using suppositories and enemas with minimal short two to three minute sitting requirements over the course of a daily treatment hour. Punishment or threats are to be avoided. This is a rational procedure. The bathroom and sitting on the toilet must become a sufficient and reliable cue for an automatic voiding response to readily take over from the initial holding response, resulting in a bowel movement. The toilet has been associated with distress and holding which any threat would make worse. Stress makes you tense or clamp up, which is NOT what we want! We want successful sits which will surprise and please your child! The suppositories and enemas are rectal primers. They are used to promote training! The colorectal brain mechanism recognizes voiding sensations, distinguishes be12

The Breakthrough!

Rectal Primers

CKMV-2nd Printing on Eliminative Disorders

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Old and New Views

tween gas and solid (not liquid), and signals the brain, to hold and then release successfully when the toilet is reached. This sequence is reinforced by relief from colon pressure and urges. Virtually all children who fight the suppositories and enemas express surprise and great happiness with a successful bowel movement. The relief and success are themselves natural reinforcers. Immediate and Early Success! A daily bowel movement literally disarms most kids from another bowel movement until the next day’s treatment hour. Ninety percent of the children stop soiling within two weeks, even though the daily treatment hour may need to be continued for weeks or even months. The changes in the child and in the family dynamics are just incredible as normalcy returns. Teachers frequently note positive changes in the child as they have better concentration; coaches note better performance, and parents note that the children become more outgoing and happy. The children’s appetites markedly improve in many instances and even growth spurts have been noted. These are all natural and highly reinforcing consequences. Doctors are not reimbursed for the time to more carefully and systematically explain and persuade the parents that they may face years of encopresis and resultant negative emotional and physical consequences if they do not try a different approach. Add telling the parent that they have to poke something into their child’s bottom which is generally regarded as a one-way exit requires a lot of reassurance and explanation! Is there an unconscious unintended mutual conspiracy of the parent and physician to find solace in the assurance that the child “will grow out of it?” I have heard hopeful claims that the problem will resolve at puberty. However, one-third of constipated children in one study had persistent and severe complaints of constipation beyond puberty!8 This makes a strong case for earlier interventions with the Soiling Solutions® protocol.

Cultural Fears and Resistance!

Wait for Puberty?

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Ginkel, R.v., Reitsma, J.B., Buller, H.A., van Wijk, M.P., Taminiau, J.A.J.M. & Benninga, M.A. (2003) Childhood constipation: Longitudinal follow-up beyond puberty. Gastroenterology 125, 357-363.

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CKMV-2nd Printing on Eliminative Disorders

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Old and New Views

SOME CAUTIONS
Policies and Change Soiling Solutions® policies and prices are subject to change. Check our website out at www.encopresis.com for the most current policies and prices. There is an unconditional money-back guarantee on the cost of your manual alone (not including postage and handling fees). If you are dissatisfied with it for any reason and return it within 120 days of purchase, regardless of its condition, its original purchase price will be returned to you. This warranty only applies to manuals purchased directly from the Soiling Solutions® website. A reason for your dissatisfaction is not required. I do not provide professional services to individuals or groups. I will do consultations with your health professionals for free. I will not provide expert testimony for any court proceedings. I have retired from the practice of psychology and no longer carry malpractice insurance. I am strictly an author of a self-help manual and a moderator for the associated Soiling Solutions® Parents’ Forum which came with your purchase. Readers should rely on local professionals who should be or become well-versed in the application of the Soiling Solutions® protocol. Physicians will learn from you. You will be natural allies in defeating this problem. Your professional should be licensed by your state and carry malpractice insurance. You can advise your professional that our manuals are available to them at a considerable discount. They can just click on the “Store” tab on the www.encopresis.com website. After they click on that they will find a hyperlink at the top, “CKM for Professionals” which will enable them to begin the ordering process. All professional orders are checked for their legitimacy simply by going to the internet. Another hyperlink on entering the store at the far left on top is “CKM for Families and Individuals.” That allows you to order the manual directly for yourself. Additional copies can be purchased at half-price. Why do professionals get a break? Well, they can order the CKM for you and it is the best way to get this manual out into physicians’ hands for promoting a wider use of this very successful treatment approach in their local 14

Win-Win Unconditional Money Back Guarantee

Author Only!

The Encopresis Store for You and Your Doctor

The Going Local Goal!

CKMV-2nd Printing on Eliminative Disorders

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Old and New Views

communities. Also, as an author far removed and unable to interact with you in a professional setting you are better off with a local licensed professional for guidance and back up. Dealing with Your Doctor Many doctors throughout the world may be put off by our retraining approach to the treatment of encopresis with suppositories and enemas. The medical profession tends to restrict their use of these agents to emergency rooms or strictly for clean out purposes. However, some doctors are open and find the Soiling Solutions® protocol persuasive and worthy of a trial. I find local general practitioners and pediatricians to be more willing to try it than the specialists. However, do not allow your doctor to alter the Treatment Hour requirements in the manual or the timing of tapering off of stool softeners. Remember, it is a behavioral retraining schedule, not a mechanical clean out or basic maintenance schedule. Also, the notion of using the rectal primers as punishment or a threat must be avoided. You want the child to become independent and self-initiate his bowel movements. This protocol even works for previously untrained children. You were registered onto the Soiling Solutions® Parents’ Forum with your purchase from our website at no additional charge. Look for an email that explains its operation. The forum was initiated in 2004. It has made a huge difference in overcoming parents’ fears, resistance and delays in initiating the Soiling Solutions® protocol. If you did not get acknowledgment of being added to the Soiling Solutions® parent’s forum or have not seen any forum traffic send an immediate email request to DrC@encopresis.com. The exclusive Clean Kid Parents’ Forum is what I regard as a natural clinical lab to gain insight into the results of your using the Clean Kid Manual. It helps me to revise future versions of this manual. It is an honest, ongoing display of the warts and all involved with the Soiling Solutions® protocol and in dealing with encopresis. It is a dramatic new way of obtaining information about how my protocol works or where and how it may fail. You parents in the trenches are informing me!

Peer Support and Advice

The Clinical Lab

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CKMV-2nd Printing on Eliminative Disorders The Control Lab

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Old and New Views

There are other open forums on the internet which I follow and which allow me to look at the common cultural practices of parents and physicians at large in dealing with encopresis or enuresis. Usually, those parents on other forums have no common guide and are just floundering about, playing at the edges with encopresis. This is a kind of comparison of treatments approach in comparing the Soiling Solutions® parent’s forum to the at large on line forums. However, true scientific comparisons between Soiling Solutions® and the current dominant diet and top down use of stool softeners, diet, and laxatives must eventually be tested in a more controlled study at a major medical center with randomly assigned subjects to treatment groups. I am optimistic about our treatment protocol and have found some instances of success for a variety of special needs and younger children. If an apparently normal child younger than four years is showing very strong holding behaviors and avoiding BOWEL MOVEMENTS at all costs then the Soiling Solutions® protocol may be appropriate if you have the support of your physician or a psychologist. It is your judgment call as to using the CKM with a child younger than four years. The Soiling Solutions® protocol can be adapted for older children who can view it with hope on reading and hearing about it. They will require sensitive parenting and supervision. They have learned much resistance to typical demands not to soil so you will have to recruit them. I do not recommend attempting treatment if your household is in a chaotic state or does not allow the same responsible supervising parent to be present at critical intervention times. Post-divorce situations are a special problem if there is severe parental alienation and the child is shuttled between households. This is especially true if there are long vacation periods with the reluctant parent. Please do not expect magic; you know your partner or ex-partner best. Sometimes ordering an extra manual (at half-price) can be helpful in fostering cooperation with the ex-spouse. Inconsistency in treatment and emotional issues affecting your child will make successful treatment more difficult. Sorry about that!

How Old to Start?

Hope Finally for Your Teen-Ager!

Partners or Saboteurs?

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