Six and nine-year-olds will not stop having accidents

Question

I have two boys, just turned six and nine. While occasional #1 accidents are not that uncommon in Kindergarten, both of my boys started off their Kindergarten years with lots of them, including #2 accidents. Even a single #2 is way too much in school, and they both had up to two a week during the first few months.

It's been a complete and mortifying nightmare.

My oldest had lingering issues throughout kindergarten and the first months of first grade. My youngest stopped having #2 accidents after the first few months, thankfully, but had consistent #1 accidents throughout the year. He is repeating Kindergarten partially because of this issue. He's just an immature little boy who needs more time to grow up (and that's okay).

Just a few weeks ago, in the second week of summer camp, my littlest had a few #1s during the week, and then THREE #2s in a single day. It's a shame, since it's been so many months since the last time. While the school district is required to accommodate, the camp is not. He was understandably kicked out. I can only guess he reverted because it was a big change in his life, starting camp, ending his first year of school.

He's now back to his old daycare, where he's again having lots of #1s, and one or two #2s that I'm aware of. They make him clean himself, doubly make sure he washes his hands. The logical consequence is that he can't go to the pool, nor on trips, since its difficult enough to have to deal with this on site. On the occasions that he does have a #2, despite being reminded to go to the potty--and sent back to sit more, when he inevitably gets up too fast--he goes immediately to bed, no reading or singing, which means a lot to him. He'll almost proudly come up to you and say "I pooped myself."

My oldest is still having accidents, but now it's just enough to "get by". He keeps it to himself (it's only a little...which burns him, which make him afraid to go, which makes him hold it in, which is impossible, so it repeats). Only a couple times this school year the teacher will ask if he accidentally put on dirty clothes. They smell something but don't connect the dots.

This past month he has had multiple stretches of four days in a row staying totally clean, and he gets technology and allowance back when he reaches a full seven days. It's been many months since he's been allowed to play a video game or watch cartoons. Technology means a lot to him, so I'm surprised it hasn't worked more quickly for him. Now he sees older kids with devices at camp, which seems to be making a difference.

If he does have an accident, and waits until we discover it, and we have to tell him to clean himself (which he can do just fine), then he's not allowed outside for the rest of the day, which impacts him. He needs to take care of it without us knowing about it. When he does, we can count it as a clean day.

And he absolutely knows. You smell it, you give him a few minutes to do something about it, then ask him to "show me I'm wrong", and he'll instantly get really angry. We keep reminding him that he absolutely must take care of this on his own, without waiting for us to notice it. Maybe you could convince me that "he just doesn't know it's happening", but there is no way in hell that he can't take care of himself once it's happened.

I'll admit that we did have our head in the sand regarding potty training for longer than I wish we had, and we are definitely responsible for this situation to an extent. But we weren't this neglectful by a longshot. We were consistent with "potty dance" celebrations, gave a single M&M when they went when told, two when on their own, three for #2. We also followed through with consequences, such as when they were told to go, blatantly don't do it, and then have an accident. I don't know when it spun out of control, but it's obviously past the point of just waiting it out.

We have scheduled appointments with gastro enterologists for both, and a urologist for the younger one, but I'll be honest and say that I do not believe for a second that it's medical. These specialists are hammers and my boys are nails. Of course they're going to find something wrong. A few years ago when my oldest went to the GE, she stuck her fingers inside him for less than three seconds, and then said he was encopresis I think was the term...which of course required more of her services.

Despite my skepticism, we are doing what it takes once again to rule out the medical possibilities (my wife does think that medical is indeed possible), and once again will follow through with whatever they recommend. It would be so easy to give up and just assume it's only medical. It's been going on for so long, it's such a part of their lives, it obviously feels like more than just a choice at this point.

So how do we start over with these boys? I'm hoping the 9-year-old is nearing the end of this (the first thing he tells me when I get home now is how many "clean" days he's had), but it feels like we're in for another few years with our little one, and I want to try and make it go quicker than that if at all possible.

What I really want to know, is what we can do to dig ourselves out of this huge hole we find ourselves in, ASSUMING THAT IT'S NOT A MEDICAL CONDITION.

I'm nervous for the potential parent bashing that could come from this. We're desperate and embarrassed beyond words. I'm being as honest and candid as I can so we can get some real answers. Aside from this huge enormous gaping chasm of an issue, we feel like pretty good parents.

Answer 1

You have my sympathy. Having one child with encopresis is awful. I can't really imagine accurately what it's like to have two children with this problem. Parents of children with idiopathic constipation often blame themselves and their toilet training problems (which were often present).

First a quick reassurance: a rectal examination finding stool in the rectal vault is abnormal, and indicates constipation. It also rules out anal stenosis or other problems as a potential cause of constipation. With the additional history you've provided, the proper diagnosis is encopresis. The doctor wasn't being careless. (Please take my word for it. She may well have been flip or nonchalant, but she wasn't necessarily careless.)

Because the rectal vault (the last few inches of the rectum) has a lot of nerve endings, it is pretty sensitive to the presence of stool. Normally, when stool enters the rectal vault, people get the urge to "go". Poor innervation or loss of innervation, voluntary holding back of stool, chronic constipation for any reason, etc. can cause the rectum to become both distended and desensitized to the presence of stool.

Normal people can hold stool in the rectum, but they know it; it's a voluntary action and it's not very comfortable; the greater the volume of stool (or the more liquid it is), the more uncomfortable it becomes. Stool just inside of the anus in a social situation causes that panicky feeling of needing to find a bathroom immediately!. But if someone holds in stool for a long enough time time (and kids do this often enough), that discomfort eventually goes away, and with it's departure, the is no more urge to go. To a greater or lesser degree, this is likely to be what's going on with your boys.

It will come as absolutely no surprise to you that this causes serious distress to the parents; to the kids? Not so much overt stress, but lots of buried problems.

And he absolutely knows.

Yes and no. The degree of desensitization (even to smell) is pretty astonishing in these kids. But you're right that stool in contact with the skin burns, and acts as a disincentive to pass more stool.

I'll be honest and say that I do not believe for a second that it's medical.

Again, well, yes and no. If encopresis is due to denervation of a segment of colon, it is most definitely medical. If it is due to psychosocial issues, it becomes medical. Right now, with your sons, it's medical, and they need to see, both of them, a good pediatric gastroenterologist who has a lot of experience with encopresis. Most likely, their treatment will require a multidisciplinary approach.

[W]hat [can we] do to dig ourselves out of this huge hole we find ourselves in, ASSUMING THAT IT'S NOT A MEDICAL CONDITION.

I'm sorry. Lately I try to write answers that limit themselves more or less to only what is asked. But I can't here.

You cannot dig yourselves out of this hole. You need a lot of experienced, professional help, and a lot of support.

Please see this question and this answer. I could write a book chapter on encopresis, but I'm sure it's been done many, many times.

Things that often don't work with encopresis: - big-time punishments
- humiliation (if it really did, they'd be humiliated at school and they'd stop)
- expecting a child to know why they have encopresis (can you explain why your heart beats the way it does? I mean the heart's sinoatrial pacemaker cells and the electrical conduction pathways? I don't think so. But your heart beats anyway.) They don't actually know.
- forcing them to sit on a toilet too long - fighting with your boys about it

You acknowledge the vicious cycle of encopersis and the child's lack of understanding/intellectual disconnect when you say

He keeps it to himself (it's only a little...which burns him, which make him afraid to go, which makes him hold it in, which is impossible, so it repeats). Only a couple times this school year the teacher will ask if he accidentally put on dirty clothes. They smell something but don't connect the dots.

And I've only addressed their bowel problem. The bladder is related, but a whole other problem. However, there are some promising new laxatives being used for the problem, and there's reason to believe this can be a thing of the past a year from now.

Please read about chronic idiopathic constipation and encopresis to prepare yourself for the specialist visit. Also, a food diary is never a bad idea. Sometimes a pattern related to food will emerge.

_{The following are not intended to give medical advice, but to familiarize you with the difficulty of this problem. You will learn a lot, though, and can go into your Pedi GI consult armed to the hilt with knowledge.
Constipation in Children and Young People: Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care. Pt. 6
Treatment of childhood encopresis: a randomized trial comparing three treatment protocols.
Dysfunctional Elimination Syndromes—How Closely Linked are Constipation and Encopresis with Specific Lower Urinary Tract Conditions?}

Answer 2

I don't know anything about #2, but I have a lot of experience with #1.

There is an alarm you can buy (for example http://bedwettingstore.com/bedwetting-alarms.html), and a helpful companion book, to work on the urination part of things. It works best when the child feels ready. What we did was to tell my son about the alarm and the approach, and wait until he asked me to buy an alarm. He was 8. In his case, he was dry during the day, but not at night.

You can get 504 plans for school. I believe the Americans with Disabilities Act (ADA) would also cover them in extracurricular programs.

If you can get them big enough, you can use swim diapers.

You can use large pull-ups as though they were underwear.

There have been studies that have found there is some correlation between wetting and/or soiling and ADHD.

• A. von Gontard et al. Association of Attention Deficit and Elimination Disorders at School Entry: A Population Based Study. The Journal of Urology, Volume 186, Issue 5, pp. 2027-2032. 2011. (The link goes to the journal article abstract; the study is discussed in more user-friendly language in a Reuters article.)

  The authors point out that "in clinical practice children with (incontinence) and ADHD have a much lower response rate to treatment than those with incontinence alone due to a lower compliance."

• Michael W. Mellon et al. Incidence of Enuresis and Encopresis Among Children With Attention-Deficit/Hyperactivity Disorder in a Population-Based Birth Cohort. Academic Pediatrics, Volume 13, Issue 4, pp. 322-327. 2013. (This blog post points out that having a "big picture" understanding of a child, including a possible ADHD diagnosis, can " be helpful in determing [sic] the best treatment plan".)

These problems do not necessarily mean that one or both of your children have ADHD, but in order to identify management and coping strategies, it is helpful to know what you're dealing with, and then you can learn what has helped others with the same condition. So, you may want to evaluate your children for possible ADHD.

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Edit -- I couldn't agree with you more about stimulant medication being overused! Sorry for not making that clear. Having a discreet ADHD diagnosis in your back pocket need not automatically lead to medication, I see it as simply providing the parent with additional information, to make her job easier.

An ADHD diagnosis, if a parent is given one, doesn't need to be shared with the school or anyone else. If you ask for a 504 plan, and the school pushes you for a diagnosis, you can give them a euphemism such as Executive Control difficulties, for example.