160 Chapter 19
involved, since (unlike enuresis) there is a high chance that psychological
problems have either contributed to the soiling or resulted from it.
Constipation with overflow
Children can become constipated for many reasons. A constitutional
liability combined with a low-fibre diet is important in some cases. In
other instances, an episode of constipation may be initiated by deliberate
retention on the part of the child, perhaps because an anal lesion (such
as a fissure) makes defecation painful, or perhaps because of a ‘battle of
wills’ over toilet training. Whatever the initiating process, constipation can
become self-perpetuating. A large faecal plug is hard to pass and the child
may give up for fear of the consequences, promoting further retention.
In addition, as the rectum becomes increasingly distended, ‘rectal inertia’
may set in, with loss of the stretch response that normally results in a
sensation of fullness and desire to defecate. Eventually, liquid or semi-
liquid faeces may leak round the blockage and overflow.
The appropriate management is to unblock the bowel and re-establish
a normal toilet routine. From the outset, the child and family’s anxiety
and anger need to be defused by adequate explanations of the underlying
physiology. Recovery is best promoted by a calm family atmosphere with
positive expectations. Clearing the bowel may be possible by using a
stimulant laxative, such as senna, in combination with a stool softener
such as lactulose; microenemas or phosphate enemas may be needed
initially; bowel washouts are only rarely required. A star chart or similar
behavioural programme is used to reward the return to a normal toilet
routine. Laxatives are replaced as soon as possible by a high-fibre diet.
Failed toilet training
Some children have never learned bowel control. This can be referred
to as primary faecal soiling, by analogy with primary enuresis. Though
sometimes associated with neurological problems, developmental delays,
and intellectual disability, primary faecal soiling may also reflect incon-
sistent, insensitive or neglectful toilet training, usually in the context of
multiple social and family disadvantages. Suboptimal training may have a
particularly marked impact if the child is exposed to chronic psychological
stresses during the toddler years when bowel control is usually acquired.
Behavioural treatments based on careful record keeping, realistic targets,
star charts and appropriate rewards are generally suitable. The most
challenging task is often to ‘sell’ the behavioural package to the family
and then ensure that it is correctly and consistently carried out.
Toilet phobia
Some children are scared of the toilet, for example, fearing that monsters
live there, or that a hand will reach up and grab them. Parents are only
sometimes aware of these fears, so it is important to explore possible
anxieties through conversation, play and drawing, usually with the child
on his or her own. The family can then be helped to discuss the child’s