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OBJECTIVE. The objective of this study was to examine differences in intellectual capacities between children with and without soiling, daytime wetting, and bed-wetting.METHODS. This study was based on a population of >6000 children (age range: 7 years 6 months to 9 years 3 months; median: 7 years 6 months) from the United Kingdom–based Avon Longitudinal Study of Parents and Children. Data on wetting and soiling were obtained from a questionnaire completed by parents. The Wechsler Intelligence Scale for Children–Third Edition was administered at a research clinic.RESULTS. Bed-wetting was associated with lower Wechsler Intelligence Scale for Children–Third Edition IQ scores compared with control subjects, particularly performance IQ. This difference remained after exclusion of children with an IQ of CONCLUSIONS. It is hypothesized that the differences in intellectual capacities between children with and without bed-wetting are associated with maturational deficits of the central nervous system. There was less evidence for differences in intellectual capacities between children with and without soiling and daytime wetting. The central nervous system is involved to a lesser extent in soiling and daytime wetting, because peripheral influences from the bladder and gut play a greater role.

OBJECTIVES. Previous studies, based on clinic samples, report that childhood soiling is associated with behavior problems and reduced self-esteem. This population-based study investigates the prevalence of psychological problems associated with childhood soiling.METHODS. A total of 8242 children aged 7–8 years born to mothers in the United Kingdom–based Avon Longitudinal Study of Parents and Children were studied. Parents completed postal questionnaires assessing common childhood emotional and behavioral problems, and children were asked questions at a research clinic concerning their behavior, friendships, bullying, and self-esteem. The rate of psychological problems was compared in children who soil frequently (once a week or more), those who soil occasionally (less than once a week), and those with no soiling problems (controls). Analyses were adjusted for developmental delay, gender, sociodemographic background, and stressful life events.RESULTS. Children who soil were reported by their parents to have significantly more emotional and behavioral problems compared with children who do not soil. Children who soil frequently had significantly more problems than those who soil occasionally. The rate of attention and activity problems, obsessions and compulsions, and oppositional behavior was particularly high in frequently soiling children. Children with soiling problems reported significantly higher rates of involvement in overt bullying (as both perpetrator and victim) and antisocial activities compared with controls.CONCLUSIONS. The current study finds significantly higher rates of behavior and emotional problems, bullying, and antisocial activities in children who soil compared with those who do not soil. Children who soil frequently are more likely to have these problems than those who soil occasionally.

Introduction. An information prescription is the provision of specific information to a patient on how to help manage a health problem. The Internet is being used increasingly as a source for information prescriptions, with clinicians directing patients to specific Web sites. As with any health care intervention, patients' lack of compliance is a barrier to the effectiveness of Web-based information prescriptions (WebIPs). WebIPs cannot be helpful if patients do not review the information prescribed for them. Objective. The main objective of this study was to quantify the percentage of families who visit a Web site that was specifically prescribed by their physician. In addition, the use of an e-mail reminder was used to determine if it increases the likelihood that families will visit the prescribed Web site. Finally, barriers to accessing the prescribed Web site were identified. Methods. Children were eligible if they presented to the pediatric gastroenterology clinic with chronic constipation and/or encopresis and their family had an active e-mail account and access to the Internet in their home. During their clinic visit, physicians instructed families to visit a Web site that provided educational information pertinent to their child's problem. Families were given a form with the Web-site address and a log-in identification number. Two days after their clinic visit, half of the families received an e-mail reminding them to visit the Web site. Families were contacted 1 week after their clinic visit to identify barriers to accessing the Web site. Results. Eighty-three families participated in the study. Of the 83 families, 54 (65%) visited the prescribed Web site within 1 week of their clinic visit. Families who received e-mail reminders were significantly more likely to visit the Web site than families who did not receive an e-mail reminder (77% vs 53%). This difference could not be explained by the type or speed of Internet connection or how frequently they accessed the Internet or e-mail. The most common reasons that families cited for not accessing the Web site were “I forgot” and “I didn't have time.” Few families cited technical reasons for not accessing the Web site. Conclusions. Almost two thirds of the families given a WebIP logged on to the prescribed Web site. The probability that families would access the site was increased by 45% with an e-mail reminder. Clearly, e-mail prompts improve compliance to WebIPs. As content and treatment programs continue to proliferate on the Web, it is important to identify barriers and solutions to them to improve overall compliance.

OBJECTIVE: Functional constipation and fecal incontinence are common childhood gastrointestinal conditions. Both conditions may be associated with behavioral problems. Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder of childhood, characterized by shortened attention span and hyperactivity. We hypothesize that a diagnosis of ADHD increases the risk for functional constipation and fecal incontinence. METHODS: A retrospective cohort study of children was performed by using the military health system database. Children of active-duty military personnel, aged 4 to 12 years, from October 2005 to September 2007, were included. ADHD, constipation, and fecal incontinence were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Relative risks and adjusted incidence rate ratios (IRRs) were calculated. A subgroup analysis of subjects receiving medical therapy was performed. RESULTS: There were 742 939 children identified in the study, 32 773 (4.4%) of whom had ADHD. Children with ADHD had an increased prevalence of constipation (4.1% of children with ADHD vs 1.5% children without ADHD; P < .001) and fecal incontinence (0.9% of children with ADHD vs 0.15% of children without ADHD; P < .0001). Children with ADHD had more visits than those without ADHD for both constipation (IRR 3.39; 95% confidence interval 2.59–4.43) and fecal incontinence (IRR 7.74; 95% confidence interval 5.01–11.98). Children with ADHD receiving medicinal therapy did not differ significantly from children with ADHD not receiving medicinal therapy on rates of constipation visits (P = .57) or fecal incontinence visits (P = .32). CONCLUSIONS: Children with ADHD are significantly more likely to have constipation and fecal incontinence. Medical therapy for ADHD does not impact visit rates for defecation disorders.

Urologic and gastrointestinal problems in children are of great concern to parents. In most cases, such problems represent no organic disease or serious behavior disorder but nevertheless can cause more serious complications in toilet training than parents recognize. Although bowel and bladder symptoms in otherwise healthy children typically are transient, untreated issues can spiral into physical, behavioral, and developmental problems that disrupt toilet training and maintenance of bowel and/or bladder continence. Chronic wetting and soiling may persist well into the school years and often are refractory to empirical medical treatment. Clinical experience, however, suggests that in most children these problems can be managed successfully within the realm of general pediatric practice. Two important tools for evaluation are available to the pediatrician: good normative data on bowel and bladder function in children, and management algorithms for toilet training that emphasize pathophysiologic patterns within the context of normal development. Interventions emphasize early anticipation, breaking predictable behavioral and dietary cycles that can turn acute problems into chronic problems. This is especially important during the toilet training years. Almost all children have wetting and/or soiling accidents at one time or another. As with other models of developmental milestones, transient regressions or delays in toilet training logically can be expected. Bowel maturation typically precedes bladder maturation, which is not surprising, given the respective complexities of the developmental processes.1 An estimated 15% to 20% of children will become partially toilet trained but continue to have wetting accidents after age 5.2,,3 Additionally, at least 20% of developmentally normal children 18 to 30 months of age may refuse stool toilet training at some point.4 ### Encopresis Children with encopresis (chronic fecal soiling at age 4 and older) typically soil during the day and are unaware of and unable to control their soiling accidents.5 Soiling …

Objective. To determine the incidence of toileting refusal for bowel movements and its outcome when toilet training children using a child-oriented approach. Design. Prospective study. Setting. Private suburban pediatric setting consisting of middle and upper middle class families. Methods. Healthy children between 18 and 30 months with no signs of developmental delay were enrolled in the study. Parents were given questions regarding their child's toilet training and behavior. Families were followed every 6 months during an office visit or by phone call until the child was successfully day time toilet trained. Results. A total of 482 children (255 males) completed the study. There were 106 children (54 males) (22%) who experienced at least 1 month of stool toileting refusal. There was an association between the presence of younger siblings (P = .023) and parental inability to set limits for the child (P= .017) and stool toileting refusal. Stool toileting refusers trained at a later age than the rest of the group (P < .0001). Fifty percent (22/44) of the children who trained between 42 and 48 months and 73% (8/11) of the children who trained after 48 months experienced stool toileting refusal. Sixty-one of the study children developed stool withholding during toilet training. Forty-nine (80%) of these children were stool toileting refusers (P < .00001). In 77 (73%) of the children no intervention was undertaken. Of these, the behavior lasted more than 6 months in 20. Intervention was undertaken with 29 children, either because of severe stool withholding (23) or the age of the child (6). Interupting toilet training and having the child return to diapers resulted in the child spontaneously using the toilet for bowel movements within 3 months in 24 of 27 children. Conclusion. Stool toileting refusal occurred in one in five children in this study population. Two behaviors associated with stool toileting refusal may require the intervention of the pediatrician. The first is stool withholding causing constipation which can result in rectal impaction and primary encopresis. The second is lack of successful toilet training by 42 months of age. A child who is still untrained at this late age can be a source of family conflict and stress requiring the advice and support of the pediatrician.

One area of pediatric care that strongly presents an opportunity for anticipatory guidance and clinical intervention is that of toilet training. Because most toilet training problems presenting to the health care practitioner reflect inappropriate training efforts and parental pressure, providers can, by consulting with parents, elucidate and address misconceptions parents have about the toilet training process, help parents to develop appropriate expectations about toilet training, and provide information, guidance, and support to parents for managing this potentially frustrating process. And although there already exists a plethora of information on child development in toilet training that parents can access and refer to, parents often solicit the support of health care providers at this particular stage in their child's development. The health care provider's role in toilet training is really a combination of needs assessment, information-gathering, education, counseling and support, short-term strategizing, and follow-up measures. This article focuses on approaches to and strategies for advising and guiding parents through supporting their child during the toilet training process. Toilet mastery is truly a developmental milestone in a child's life; it is a time when children are discovering and enhancing their physical abilities, understanding and responding to relationship dynamics, and confronting and reacting to external pressures. Meanwhile, as each step is achieved, their self-esteem also is developed. Toilet training also can be one of the most difficult developmental phases that both children and parents experience together, because pressures for the child to conform to parental and social expectations occur simultaneously with a child's burgeoning need for self-actualization and independence. Parental control over the child to train, concurrent with the child's will to be in control, leads to conflict and anxiety. Power struggles ensue that impact negatively the parent–child relationship and may lead to physical complications such as enuresis, encopresis, and child abuse. The American …

OBJECTIVE. Our aim was to compare 2 laxatives, namely, polyethylene glycol 3350 without electrolytes and milk of magnesia, evaluating the efficacy, safety, acceptance, and 1-year outcomes.METHODS. Seventy-nine children with chronic constipation and fecal incontinence were assigned randomly to receive polyethylene glycol or milk of magnesia and were treated for 12 months in tertiary care pediatric clinics. Children were counted as improved or recovered depending on resolution of constipation, fecal incontinence, and abdominal pain after 1, 3, 6, and 12 months. An intent-to-treat analysis was used. Safety was assessed with evaluation of clinical adverse effects and blood tests.RESULTS. Thirty-nine children were assigned randomly to receive polyethylene glycol and 40 to receive milk of magnesia. At each follow-up visit, significant improvement was seen in both groups, with significant increases in the frequency of bowel movements, decreases in the frequency of incontinence episodes, and resolution of abdominal pain. Compliance rates were 95% for polyethylene glycol and 65% for milk of magnesia. After 12 months, 62% of polyethylene glycol-treated children and 43% of milk of magnesia-treated children exhibited improvement, and 33% of polyethylene glycol-treated children and 23% of milk of magnesia-treated children had recovered. Polyethylene glycol and milk of magnesia did not cause clinically significant side effects or blood abnormalities, except that 1 child was allergic to polyethylene glycol.CONCLUSIONS. In this randomized study, polyethylene glycol and milk of magnesia were equally effective in the long-term treatment of children with constipation and fecal incontinence. Polyethylene glycol was safe for the long-term treatment of these children and was better accepted by the children than milk of magnesia.

Toileting skills are acquired through 2 simultaneous, reciprocal processes: toilet training (what parents do to help their child toward socially appropriate, self-sufficient toileting) and toilet learning (what a child thinks and does while learning the mores of elimination behavior, how to recognize sensory signals, how to choose whether to void, and how to control anal and urethral sphincters in implementing that choice). This learning process can be derailed, resulting in functional disorders of elimination. In this issue of Pediatrics , Schonwald et al1 infer that toilet training difficulties are associated with difficult temperament traits. Although constipation was more prevalent in their patients than in their normal control group, constipation nevertheless affected 55% of the latter. This result begged the question: Does constipation also contribute to toilet training difficulties, or is it a secondary epiphenomenon? In this month’s Pediatrics Electronic Pages , Blum et al2 confirm that constipation is contributory to the type of difficulty referred to as stool toileting refusal rather than a result of … Address correspondence to David R. Fleisher, MD, University of Missouri School of Medicine, One Hospital Drive, Columbia, MO 65212. E-mail: fleisherd{at}health.missouri.edu

Objective. Constipation and encopresis are common problems in children. Still today, the role of fiber in the treatment of chronic constipation in childhood is controversial. The aim of our study was to evaluate whether fiber supplementation is beneficial in the treatment of children with functional constipation with or without encopresis. We used glucomannan as the fiber supplement.Methods. We evaluated the effect of fiber (glucomannan, a fiber gel polysaccharide from the tubers of the Japanese Konjac plant) and placebo in children with chronic functional constipation with and without encopresis in a double-blind, randomized, crossover study. After the initial evaluation, the patients were disimpacted with 1 or 2 phosphate enemas if a rectal impaction was felt during rectal examination. Patients continued with their preevaluation laxative. No enemas were given during each treatment period. Fiber and placebo were given as 100 mg/kg body weight daily (maximal 5 g/day) with 50 mL fluid/500 mg for 4 weeks each. Parents were asked to have children sit on the toilet 4 times daily after meals and to keep a stool diary. Age, frequency of bowel movements into the toilet and into the undergarment, presence of abdominal pain, dietary fiber intake, medications, and the presence of an abdominal and/or a rectal fecal mass were recorded on a structured form at the time of recruitment and 4 weeks and 8 weeks later. Children were rated by the physician as successfully treated when they had ≥3 bowel movements/wk and ≤1 soiling/3 weeks with no abdominal pain in the last 3 weeks of each 4-week treatment period. Parents made a global assessments to whether they believed that the child was better during the first or second treatment period.Results. Forty-six chronically constipated children were recruited into the study, but only 31 children completed the study. These 31 children (16 boys and 15 girls) were 4.5 to 11.7 years of age (mean: 7 ± 2 years). All children had functional constipation; in addition, 18 had encopresis when recruited for the study. No significant side effects were reported during each 4-week treatment period. Significantly fewer children complained of abdominal pain and more children were successfully treated while on fiber (45%) as compared with placebo treatment (13%). Parents rated significantly more children (68%) as being better on fiber versus 13% as being better on placebo. The initial fiber intake was low in 22 (71%) children. There was no difference in the percentage of children with low fiber intake living in the United States (70%) and Italy (71%). Successful treatment (physician rating) and improvement (parent rating) were independent of low or acceptable initial fiber intake. The duration of chronic constipation ranged from 0.6 to 10 years (mean: 4.0 ± 2.5 years). Duration of constipation did not predict response to fiber treatment. Children with constipation only were significantly more likely to be treated successfully with fiber (69%) than those with constipation and encopresis (28%).Conclusion. We found glucomannan to be beneficial in the treatment of constipation with and without encopresis in children. Symptomatic children who were already on laxatives still benefited from the addition of fiber. Therefore, we suggest that we continue with the recommendation to increase the fiber in the diet of constipated children with and without encopresis.

Objective. To compare the characteristics of children with encopresis referred to a single encopresis clinic over the course of 20 years, including symptoms, previous diagnostic and therapeutic interventions, and parental attitudes.Methods. A retrospective study was conducted of an encopresis clinic at a tertiary care pediatric hospital. Questionnaires at initial evaluation elicited information about bowel habits, soiling, previous evaluations, previous treatments, and parental attitudes.Results. In 503 children with encopresis, the average age of referral dropped from 115 months during the earliest 5 years to 77 months during the most recent 5 years. Children who had soiling for >3 years before referral decreased from 63% to 12%. The use of barium enema before referral decreased from 14% to 5%, as did psychological evaluation, from 25% to 14%. Previous therapy with enemas decreased from 45% to 27%. Mineral oil use remained at approximately 50%, and 20% of children had no previous treatment. Symptoms at referral and parental attitudes did not change across the years.Conclusions. Children are now referred at an earlier age to our tertiary encopresis clinic. The number of invasive and psychological evaluations has decreased before referral. However, treatment by many primary care providers before the referral has not changed. These data may suggest that pediatricians have increased awareness of encopresis and greater appreciation of its primarily physical rather than psychological nature. Additional studies will be needed to determine how these factors affect outcome.

Abnormalities of hormones affecting gastrointestinal motility have been found in "functional" disorders of the gastrointestinal system in adults. One such disorder of childhood, encopresis, is frequently associated with constipation, the treatment of which often eliminates the soiling. We hypothesized that hormones affecting gastrointestinal motility were different between encopretic patients and matched controls.Ten encopretic patients were matched by age, race, and sex with controls who had no history of encopresis or constipation. After an overnight fast, each child consumed a meal of Ensure, the amount of which was based on body weight. Plasma levels of gastrin, pancreatic polypeptide, cholecystokinin, motilin, thyroxine, estrogen, and insulin were measured 20 and 5 minutes before the meal, and 5, 10, 15, 30, 45, 60, 90, 120, 150, and 180 minutes after the meal.Postprandial levels of pancreatic polypeptide remained consistently higher and peaked earlier (P.05) for encopretic patients. The motilin response was lower (P.03) for encopretic children than for controls.We conclude that pancreatic polypeptide and motilin responses to a meal are different in encopretic children than in children in the control group. These gastrointestinal hormone findings may in part explain and/or be the result of the severe constipation that frequently underlies the fecal soiling found in these patients. These findings also suggest the motility of the stomach and small intestine may be abnormal in encopresis.

Abnormal defecation dynamics often are present in children with chronic constipation and encopresis. Patients who learned normal defecation dynamics with biofeedback treatment had improved short-term outcome. The aim of our research was to evaluate if biofeedback treatment improved long-term outcome.One hundred twenty-nine children with constipation, encopresis, and abnormal defecation dynamics were treated conventionally; 63 of them received additional biofeedback training directed towards teaching normal defecation dynamics.At follow-up (4.1 +/- 1.5 years), 86% of conventionally treated patients and 87% of biofeedback-treated patients had improvement in encopresis; 62% of conventionally treated patients, 50% of successful biofeedback-treated patients, and 23% of unsuccessful biofeedback-treated patients had recovered from chronic constipation and encopresis. Recovery rates were similar for conventionally treated patients and biofeedback-treated patients who learned normal defecation dynamics (P.2) but significantly lower for unsuccessful biofeedback-treated patients (P.02). Length of follow-up was significantly related to recovery (P.01).Learning normal defecation dynamics with biofeedback training did not increase long-term recovery rates in children with chronic constipation, encopresis, and abnormal defecation dynamics above those achieved with conventional treatment alone.

Chronic constipation accounts for 3% to 5% of pediatric primary care outpatient visits. The most severely affected of this group develop a flaccid colon insensitive to distention, and encopresis. Laxatives and lubricants have been the standard therapeutic agents during the bowel decompression phase of encopretic therapy. Fiber has been the cornerstone of maintenance programs. Each of these agents is accompanied by considerable anxiety in the lay literature. This study evaluates the safety of combined high-fiber, laxative, and lubricant therapy on bowel movement frequency, fecal soiling, and nutritional status over a 6-month period. Blood chemistry values, dietary fiber intake, defecation pattern, and psychological profile were evaluated before and after the 6-month study. Biochemical and anthropometric indicators of nutritional status were not adversely affected by the therapy. Seventy-five percent of the children were able to remain free of soiling and the remaining 4 of 16 had soiling episodes reduced to a frequency of less than once a week. This study confirms that children with encopresis can respond to a combined program of increased fiber intake, laxatives, and mineral oil following a complete bowel cleanout, without experiencing deleterious effects.

Objective.Approximately 50% of constipated children contract rather than relax the external sphincter complex during a defecation attempt. Although biofeedback training (BF) is able to change this defecation behavior, there is no additional effect of BF to conventional treatment (CT) on clinical outcome compared with CT alone. It has been postulated that the absence of a significant difference between these 2 treatment options might be because of a therapeutic, “demystifying” effect of performing anorectal manometry in conventionally treated children, necessary to obtain basal manometric data. The objective of this prospective, controlled, randomized study was to evaluate the effect of CT with 2 anorectal manometry sessions compared with CT alone (dietary advice, diary, toilet training, oral laxatives, and enemas) on clinical outcome.Methods.A total of 212 constipated children (143 boys) who were visiting a referral pediatric gastroenterologic practice were randomized prospectively to CT alone (115 patients) or to CT combined with 2 manometry sessions (CTM; 97 patients). Patients were included in the study when they fulfilled at least 2 of the 4 following criteria: stool frequency fewer than 3 per week, 2 or more soiling and/or encopresis episodes per week, periodic passage of very large amounts of stool every 7 to 30 days, or a palpable rectal or abdominal fecal mass. CT comprises dietary advice, a daily diary, toilet training, and oral laxative treatment preceded by rectal disimpaction with enemas on 3 consecutive days. During both manometries, the child and the parent could watch the tracing on the computer screen. No explanation was given to either the child or the parents during the procedure. When the procedure was finished, the tracings were clarified. Successful treatment was defined as a defecation frequency of 3 or more per week and fewer than 1 soiling/encopresis episode per 2 weeks and no use of laxatives.Results.Only 4 and 2 children from the CT and CTM groups showed no soiling and/or encopresis, whereas 76% and 65%, respectively, reported the periodic passage of large stools. In 26% and 30% of the patients, a rectal scybalum was found on physical examination. The success rates at 6, 26, 52, and 104 weeks' follow-up were 4%, 24%, 32%, and 43% and 7%, 22%, 30%, and 35% in the CT and CTM group, respectively. No significant difference in success percentage was observed between the 2 groups at any time of follow-up with relative risks (CT/CTM) and 95% confidence intervals, respectively, of 0.55 (0.16–1.89), 1.13 (0.67–1.89), 1.07 (0.69–1.65), and 1.23 (0.81–1.85). A significant increase in defecation frequency was observed between the first (intake) and second visits, which was sustained at all subsequent visits and stages of follow-up in both groups (not significant). Also in relation to the first visit, a significant decrease in encopresis episodes was shown and a further slow but significant decrease at 52 weeks of follow-up in both groups. The manometric data obtained from the CTM group showed a low percentage of children with normal defecation dynamics, namely 28%, which (significantly) increased to 38% at the last manometry.Conclusions.Anorectal manometry combined with CT compared with CT alone did not result in higher success rates in chronically constipated children. Therefore, anorectal manometry has no additional demystifying or educational effect on clinical outcome in chronically constipated children. This observation together with the observation in the current and previous studies that no correlation was found between (achievement of) normal defecation dynamics and success and that no relation was observed between volume of urge or critical volume and success leaves no diagnostic or therapeutic role for anorectal manometry in chronic constipated children, except its use as a diagnostic test to exclude Hirschsprung's disease. A simple CT is successful in 30% of severely constipated children who are referred to a tertiary hospital, underscoring the importance of long-lasting and adequate laxative treatment.

To the Editor.— I was intrigued by Dr Pilapil's comments in his reply regarding the case of stool withholding reported by de Vos et al in the February 1991 issue of Pediatrics.1 It would be pertinent to consider some of the possible byproducts of one element of Pilapil's therapy of his case reported in the April 1990 issue of Pediatrics.2 One must be alert to the possible "anxiety-provoking situation" of exposing this 3-year-old child to the toileting functions of his family.

In Reply.— I appreciate Dr Weintraub's thoughtful comment regarding my reply on the report on encopresis by de Vos et al.1 In reality, the plan for the case I described2 was for the mother to familiarize the child with the nature of the toilet setting and to demonstrate casually the safety and harmlessness of sitting on the toilet but not necessarily at the time of the private function. However, that was the extent to which it was carried out by the mother, perhaps with the thought that it was a more realistic approach.

The social competence and behavioral profiles of 38 encopretic children were evaluated, and the social competence and behavioral ratings were correlated with physiologic abnormalities found during anorectal manometric and EMG evaluation and with treatment outcome. When defecation was studied, 66% of encopretic children were not able to defecate rectal balloons and 63% were not able to relax the external anal sphincter during defecation attempts. Total social competence and behavior problem scores were not different for boys able and unable to defecate balloons. Total social competence scores were significantly lower in girls unable to defecate balloons than in those able to (P < .006), whereas behavior problem scores were similar in girls able to and unable to defecate. We found that persistence of encopresis at 6-month and 12-month follow-up was not related to the social competence (P > .2) or behavioral scores (P > .2) but was significantly related to the inability to defecate (P < .01) and to the inability to relax the external sphincter during defecation attempts (P < .03).

A pediatric treatment program for encopresis was established in a large medical center. This consisted of counseling and education, initial bowel catharsis, a supportive maintenance program to potentiate optimum evacuation, retraining, and careful monitoring and follow-up. A group of 127 children received care for this problem. At the end of one year, outcome data were obtained on 110 patients. Of these, 51% had not had "accidents" for more than six months. Another 27% showed marked improvement and were having only rare episodes of incontinence. 14% of these children showed some improvement, but continued to have incontinence, while 8% showed no improvement whatsoever during the treatment year. These four outcome groups were compared with respect to a large number of demographic, developmental, psychosocial, and clinical variables.

During an 18-month period, 102 children with encopresis were seen in a general pediatric outpatient clinic. Through interviews and questionnaires, extensive historical information was obtained. Children were compared with respect to demographic characteristics, bowel-function histories, early training and management, and present manifestations of bowel dysfunction. A wide variety of historical backgrounds and manifestations was observed. It was found that many of the traditional generalizations about encopresis could not be substantiated. It is suggested that a very individualized approach to this problem be adopted and that children with encopresis be investigated carefully to uncover early developmental problems, critical life events, and the precise physiology and dynamics of present bowel dysfunction.

A complex is described herein, consisting of the symptoms of urinary and often fecal incontinence, and the findings of disturbed structure and evacuating function of the urinary tract, with resultant infection. Emotional imbalance alters vesicourethral function both physiologically and pathologically, and results in poor coordination between contraction of the detrusor and relaxation of the external sphincter, similar to the effects of neurogenic disorders. We have named this condition nonneurogenic neurogenic bladder. If surgical correction of this structural damage is to succeed it must follow restoration of coordinated voiding, brought about by a program of anticholinergic drug administration, antibacterial therapy, correction of constipation, parental instruction, and finally strong suggestion often including hypnosis.

Pediatricians are increasingly recognized as the providers of choice for children with functional encopresis. The presence of clinically significant behavior problems could interfere with pediatric regimens for encopresis, however. To study the extent to which encopretic children exhibit behavior problems, we compared the scores on a standardized behavioral checklist for three randomly selected samples: a sample group of children with encopresis, a sample group of children with behavior problems, and a sample group of children without encopresis or behavior problems. All three samples were matched for age and gender. An analysis of variance showed that the scores of children with encopresis did not differ from the normative sample but were significantly lower than the scores from the behavior problem sample (P less than .00001). The results support the appropriateness of the trend toward expanding the primary pediatrician's role in the treatment of encopresis.

A pediatric treatment program for encopresis was established in a large medical center. This consisted of counseling and education, initial bowel catharsis, a supportive maintenance program to potentiate optimum evacuation, retraining, and careful monitoring and follow-up. A group of 127 children received care for this problem. At the end of one year, outcome data were obtained on 110 patients. Of these, 51% had not had "accidents" for more than six months. Another 27% showed marked improvement and were having only rare episodes of incontinence. 14% of these children showed some improvement, but continued to have incontinence, while 8% showed no improvement whatsoever during the treatment year. These four outcome groups were compared with respect to a large number of demographic, developmental, psychosocial, and clinical variables.

Though a frequent problem with a tremendous negative impact on the family as well as the child, fecal incontinence has received little attention in the pediatric literature. Levine's study of the natural history of children with encopresis in this issue of Pediatrics is, therefore, a welcome contribution. Encopresis is defined as incontinence of feces not due to organic defect or illness. Mercer preferred to define encopresis as the voluntary or involuntary passage of an ordinary bowel movement into the clothing, and soiling as the constant involuntary seepage of feces associated with impaction. He reported that the former was rare in his experience.