ato Ciel Ci Prey Cognitive-Behavioral Play Therapy in the Treatment of Encopresis Susan M. Knell and Douglas J. Moore Child Guidance Center of Greater Cleveland Cleveland State University Discusses a unique cognitive-behavioral play therapy approach utilized with an ‘encopretic child. A 5-year, 3-month-old male triplet presented with primary nonretentive encopresis, as well asa language disorder. The treatment included individual cognitive-behavioral play therapy with the child, which was yoked toa parent-implemented behavioral management program. Treatment success, defined as the child’s ceasing soiling and demonstrating appropriate toilet use, was maintained through 45-month follow-up. ‘There is a growing literature on the treatment of encopresis (passage of feces into inappropriate places). Despite an increase in our knowledge regarding the disorder and its manifestations, encopresis remains a difficult problem to treat. Interventions have typically fallen into one of four broad categories: traditional insight-oriented ther- apy (including verbal and/or play techniques), ‘behavioral treatments, medical interventions, and utilization of mechanical devices. Many interven- tions reflect a combination of two or more general approaches, ‘The highest treatment success rates have been reported for comprehensive behavioral treatments (Werry, 1986). The primary focus of the behav- {oral interventions has been the contingent positive reinforcement of appropriate defecation (c.¢., Ayllon, Simon, & Wiliman, 1975). Additional components, such as mild’ punishment (.g., Edelman, 1971), extinction (e.g., Conger, 1970), and biofeedback (e.., Kohlenberg, 1973), have been employed. Several systematic programs use a combination of reinforcement and punishment techniques along with medical procedures (.g., Aztin & Foxx, 1974; Doleys & Amold, 1975; Wright & Walker, 1976), A previous version of this amtisle was presented at the Rivendell Conference for Clinical Practitioners, Memphis, Deccember 1986 'A portion of this work was completed while Suran M. Knell vasa staf? psychologist at Kaiser Permanente Medical Center, Parma, OH. We acknowledge E. A. Klonof? for her asistance in the treatment design. Requests for feprnts should be sent to Susan M. Knell, ‘Child Guidance Center of Greater Cleveland, 2525 East 22nd Street, Cleveland, OH 44115, A growing body of the behavioral literature on encopresis addresses treatments that use parent- implemented interventions, with minimal contact between therapist and child (Siegel, 1983). Most striking, and perhaps most problematic, isthe level of resistance and noncompliance frequently seen in encopretic children in parent-implemented behav- ioral interventions. The need for children to change their own behavior and be active participants in treatment is important, and often ignored. ‘One method for including children in treatment is to use cognitive therapy, a structured, focused, intervention that teaches individuals to correct cognitive distortions. Downward extensions of the literature on treating adults with cognitive therapy have begun to address younger populations such as depressed children and adolescents (e.¢., Emory, Bedrosian, & Garber, 1983) and impulsive children (¢.g., Kendall & Braswell, 1985). Consideration of developmental issues is crucial in such adaptations of interventions originally designed for adults. The integration of develop- ‘mental concerns in behavior therapy was ad- ressed by Harris and Ferrari (1983). Of particular he lack of attention paid by behavioral therapists to very young (ie., pre- school age) children. Play is the main modality of expression for preschoolers and an effective means ‘of communicating with them. Although tradition- ally, play has been a main treatment approach for preschoolers, virtually no attention has been fo- ‘cused on incorporating cognitive or behavioral principles into play situations, This article discusses a new treatment approach for young children that integrates cognitive- ‘behavioral principles and play. The intervention is presented in the case of a 5-year-old encopreticNEL & MOORE boy. He was treated with structured, focused cognitive-behavioral play therapy in combination with a parent-implemented contingency manage- ‘ment program. Cognitive-behavioral play therapy ‘was conceptualized to help the child incorporate positive self-statements and more adaptive coping skills. Although many behavioral treatments of encopresis are successful without such compo- nents, these cognitive interventions might directly address the child’s distortions and misperceptions about the presenting problem. Method Subject A S.year, 3-month-old boy presented with pri- mary functional nonretentive encopresis. He was the most quiet and passive of a set of male triplets. The child had repeatedly stated that he did not want to be like his brothers, and according to parental report became angry when people could not tell them apart. Independent evaluation cated he was in the average range of intelligence, although he did have developmental expressive and articulation language disorders. The child was referred t0 a child psychologist (Knell) by his pedi- atrician, after a medical workup revealed no or- ganic etiology for the soiling. He had no other known medical or psychological conditions. His parents reported that he soiled several times daily, and if not changed by an adult, would remain in soiled pants. No history of constipation was reported. The child had been minimally re- sponsive to medical interventions (e.g., diet mod- ifications) attempting to alleviate the soiling. All attempts to train him to use the toilet for bowel ‘movements were unsuccessful, although he suc- cessfully had been trained to use the toilet for urination at 3 years of age. The child denied being afraid of toilet use, nor had he exhibited behavior suggestive of a toilet phobia, However, he did state that he did not want to learn to use the toilet and be like his brothers, both of whom were completely toilet trained. Procedure Baseline data were collected for 12 days. During baseline, the parents checked the child’s pants for : E i al sb os 3e ° tt ta L ; Oa re ae eee ae eee es 45-month follow-ups, mother reported the child was using the toilet for bowel movements regularly and appropriately.(COGNITIVE-BEHAVIORAL PLAY THERAPY evidence of soiling at four times (12:30 p.m., 3:30 p.m., 6:30 p.m., and bedtime). Soiling was de- fined as evidence of any fecal material or fresh discoloration of the underpants. The parents were instructed to remain neutral in interacting with the child while checking his pants, and merely ex- plained to him that they needed to see if his pants ‘were “clean or soiled.” Any soiling that occurred during these time periods was recorded at the prescribed times (see Figure 1). ‘Treatment ‘The therapist used cognitive-behavioral play therapy with the child and concurrently worked ‘with the parents in the behavioral management of the child’s encopresis. The child and parents were seen on a weekly basis with the child’s therapy taking half the session and work with the parents the other half. Cognitive-behavioral play therapy. The child ‘was seen in individual cognitive-behavioral play therapy, which was initiated after the collection of baseline data. Structured, directive behavioral in- terventions were incorporated into a more tradi- tional, nondirective play therapy approach (Axline, 1947), Initially, much of the time was spent with the child playing spontaneously. His struggles with toileting and competition with his brothers could be seen in his play. The therapist systematically took specific themes and structured the cognitive-behavioral intervention to address these issues. Sample vignettes from this treatment, illustrating the integration of cognitive-behavioral approaches within play, can be found in Tables 1 and 2. ‘The child initially denied the fear of the toilet often evident in children as they learn appropriate toilet use. However, in therapy he repeatedly made a stuffed bear fall into the toilet and be “flushed away.” The therapist acknowledged the repetition of this theme (identification of irrational belie), sradually had the bear sit on the toilet (shaping), without getting flushed down it (exposure, re- sponse prevention), and stated that the bear would not get flushed away (changing an irrational be- lief). ‘The therapist repeated positive self-statements for the bear. Included were statements intended to counter irrational beliefs (e.g., “I will not get flushed down the toilet”) and reinforce positive, ‘adaptive functioning and thought (e.g., “I will feel good when I use the toilet”). The therapist also used a stuffed bear to show how the animal expressed its feelings about using the toilet. Ver- balizing anger rather than acting it out was mod- eled for the child via the bear's activities and self-statements (e.g., “I’m mad but I can say I'm mad. { don’t need to poop in my pants to show iv). The structured situations with the bear were yoked to the child's contingency management pro- ‘gram, and were designed to be approximately one step ahead of the child’s program. Thus, for example, the bear went through a “contingency ‘management program” in the sessions, where it received stars and praise for appropriate toileting and dry pants. Gradually, the child began “com- peting” with the bear, comparing numbers of stars and expressing his wish to “beat the bear.” Behavioral management, ‘The behavioral man- agement program implemented by the parents began at the same time as the cognitive-behavioral play therapy with the child. The program con- sisted primarily of a sticker program in which the child was reinforced for nonsoiled pants and appropriate toilet use. Parents continued to check for soiling at the specified times. The child re- ceived a sticker for any time period in which he had not soiled, and was to receive a sticker for toilet use. To prompt toilet use, he was placed on, the toilet for 10 min three times per day, approx- imately 30 min after each meal. Additionally, with parental assistance, the child was taught to clean his pants and was expected to do so after he soiled. Cleaning consisted of changing his underwear Table 1. Sample Vignettes of Behavioral Techniques in Play Therapy via Modeling With Toy Bear ‘Technique Play Situation ‘Therapist Intervention Shaping ‘Cid pays with bear near tilt. “Therapist has bear gradually approach [Exposure and Response Prevention down toilet Positive Reinforcement Shaping Socially Appropriate Expression of Felines face.” Child repeatedly has bear gt flushed Bear Keeps pants clean and uses tile. (Chil says: want to punch bear's toll, make bowel movement i tll. Therapist has bea sit on toilet without eeting ushed, Bear receives praite and stickers for ‘clean pants and toilet us, ‘Therapist phrases “You're mad be-NEL & MOORE Table 2. Sample Vignettes of Cognitive Techniques in Play Therapy via Modeling With Toy Bear Technique Play Situation ‘Therapist Tatervention dentfying rational Beliefs (Changing Irrational Beis Positive Self-Statements Bear uses tole. (Child has bear repeatedly fll nto toilet. (Chit has bear repeatedly fall into toile. ‘Therapist notes child's repetition of bear being shed down toilet. “Therapist says to bear, “You won’ fal in and xt flushed down the tole.” ‘Therapist says for bear, “lca use the toilet” and “I fee! good when I use the tia.” (Kept in an easily accessible place in the bathroom) and placing his dirty underwear in a pail of soapy water in the bathroom. By Week 8, the child’s soiling had decreased. By this time he appeared to be comfortable sitting on the toilet, but he still had not had a bowel ‘movement on the toilet. Because soiling had de- creased without a concomitant increase in toilet use, there was concern that the child would be- come impacted. To increase appropriate use of the toilet, and 10 avoid fecal impaction, a negative reinforcement paradigm was used. The expectation of an enema would be removed if the child increased appro- priate toilet use by the third day. The enemas were explained to the child by saying some medicine would “help” him use the toilet if he did not use it ‘on his own. Given his history of medical interven- tions and other issues associated with use of such ‘an aversive technique, this was presented to him as calmly and neutrally as possible, by the parents. He did not use the toilet, so it was necessary to sive the child an enema. Because of his continued lack of appropriate toileting, a total of three enemas were used over the course of 9 days. The child made a bowel movement in the toilet after each of the enemas. These represented the first tree times the child had ever used the toilet for a bowel movement. The parents, provided imme- diate social reinforcers (e.g., praise) for the child’s bowel movement in the toilet. A “friends-who-care list” was also generated which reminded him of everyone who would be happy to hear of his toilet use (Azrin & Foxx, 1974). After these first three bowel movements, many of the friends and rela- tives on the list were called, and as prearranged by the parents, they praised the child’s effort. Tan- sible reinforcements, in the form of special small toys, were provided to the child after the first two bowel movements in the toilet but were not given to the child for any further toilet use. Results At baseline, the child was soiled 77% of the time. Although the child had three soiling acci- 58 dents between Sessions 12 and 14, there were no incidents of soiling after the 14th session. During baseline, the child did not use the toilet for bowel movements. After the 12th session, the child used the toilet spontaneously and regularly for bowel ‘movements. Appropriate toileting without soiling accidents was reported through the 8- and 45- month follow-ups. Parental report at the more recent follow-up indicated that in addition to his appropriate toileting, they had not experienced any other psychological or medical problems with the child, Figure 1 depicts these results. Discussion This study represents the successful treatment of primary, nonretentive encopresis in a 5-year, 3- month-old boy utilizing cognitive-behavioral play therapy and behavioral management approaches. ‘The behavioral management was similar to other reported behavioral treatments (e.g., Wright & Walker, 1976). Unique to the intervention was cognitive-behavioral play therapy, previously un- reported in the literature, which was designed to address issues that could not be addressed in the parent-implemented program. One example of this was the child’s expressed desire nor to be like his brothers. His difficulty in maintaining a sepa- rate, unique identity seemed, in part, to be mani- fested in his soiling. It gave him a way to be different, and in this sense an identity. Cognitive- behavioral play therapy could address such cogni- tive self-perceptions and self-statements. Treat- ment success, defined as the child’s complete cessation of soiling and evidence of appropriate, consistent toilet use, was maintained through 45- month follow-up. Tree limitations of this study should be noted. First, it is possible to construe data collection during baseline as a type of intervention. As part of the baseline, the parents checked the chile’s pants four times daily and recorded the child’s soiling, thus attending to the soiling on a regular basis. “Although parental attention increased around the soiling, a stable baseline was achieved. ‘Thus, increased parental attention was not suffi-‘COGNITIVE-REHAVIORAL PLAY THERAPY cient for the treatment of encopresis because no significant changes were noted in soiling or toileting until the implementation of specific inter- Second, it cannot be demonstrated which fac- tors contributed to change, as one cannot ferret ‘out the relative contributions of behavioral man- ‘agement and cognitive-behavioral play therapy in the successful treatment of the child. Given the concomitant interventions of cognitive-behavioral therapy and behavioral management, the results ‘could be explained on the basis of either treatment or on the basis of the combined treatments. nally, there is no way of ruling out maturation as an explanation for the child’s learning appro- priate toileting. However, given the dramatic changes in the child’s encopresis during treatment, and his lack of responsiveness to all previous ‘medical interventions, it seems unlikely that mat- uration alone would explain the changes. Encopresis is a complex, multifaceted disorder with differential treatment possibly required for different types of encopresis (Doleys, 1983). The applicability of cognitive-behavioral play therapy alone in the treatment of encopretic children is unknown. Currently, most interventions with encopretic preschoolers have focused on behav- ioral management of the child, without address- ing the child's cognitions and feelings. Through cognitive-behavioral play therapy the child could directly identify his anger and modify the cogni- tive distortions associated with it. In this case, the combination of play therapy and parent- implemented behavioral management may have been useful because of the child’s developmental level and perceptions of his soiling. His language isorder may also have made aspects of the play (e.g., symbolic modeling) more useful to him than a predominately verbal approach. It would be helpful to delineate further which child or family variables would be most amenable to a cognitive- behavioral play therapy approach. ‘What is cognitive-behavioral play therapy? As described in this example, it incorporates specific cognitive-bchavior therapy techniques into a play therapy paradigm. Its potential efficacy may be related to six specific properties: 1, It involves the child directly in treatment, via play. 2, Treatment is focused on the child’s feelings, thoughts, and fantasies, as well as on envi- ronmental/situational circumstances. 3. Through its cognitive focus, the child learns strategies for developing more adaptive thoughts and behaviors. 4, It is structured and goal oriented, with the therapist intervening in a directive way. 5. Itincorporates empirically demonstrated cog- nitive-behavioral techniques, such as the use of self-statements and modeling. 6. By its nature, it allows for an empirical examination of treatment (Knell & Moore, 1989). Future studies should be designed to look at specific assessment and treatment components of cognitive-behavioral play therapy. More specific assessment techniques for measuring cognitive self- statements and self-perceptions of young children should be developed. In this study, better mea- surements of the child’s perceptions about his soiling might have been useful. The effectiveness Of cognitive-behavioral play therapy alone, and in combination with other interventions, such as contingency management, should also be consid- ered. Does adding a cognitive component enhance the efficacy of behaviorally based programs? Con- versely, are there situations in which a cognitive play component either detracts from or does not ‘add to parent-focused interventions? Cognitive- ‘behavioral play therapy may be indicated when parents cannot implement management programs. For example, if the problem is too aversive to the parent (e.f., Knell & Moore, 1988), or if the parent-child relationship has inhibited develop- ‘ment of the child’s self-mastery (Klonoff, Knell, & Janata, 1984; Klonoff & Moore, 1986), the child’s direct involvement may be necessary. Specificity regarding the various conditions and treatments that have been successful with these variables is needed. Until cognitive-behavioral play therapy is stud- ied more systematically, some questions will re- main unanswered. However, at this time its major contributions appear to be threefol 1. Cognitive and behavioral treatment aspects are incorporated into a play therapy para- digm in a systematic and goal-oriented man- 2. It takes into account developmental, and particularly cognitive-developmental factors in treatment planning. 3. It is empirically based, both in its use of experimentally tested treatment approaches and in its attempts to evaluate treatment effectiveness empirically. References Axle, V. (1947) Play therapy. Boston: Houghton Mifflin ‘Ayllon,T., Simon, S.J, & Wildman, R. A. (1975). Instruc- 59tions and reinforcement i the elimination of encopresis: [A case study. Journal af Behavior Therapy and Expert imental Psychiatry, 6, 235-238, ‘Ati, NH, & Foxx, R. M. 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