Faecal Soiling 161fears openly and sympathetically, without ridicule. The fears themselves
can be addressed through appropriate reassurance and graded exposure
with rewards. Shy children may be afraid to use the toilets at school, or of
having to ask a teacher’s permission to go to the toilet during class time.
Bullied children may reasonably fear unsupervised encounters with bullies
in the school toilets.
Stress-induced loss of control
Some children acquire bowel control normally but then lose it again after
a significant stress, such as a traumatic hospital admission, marked family
discord or disruption, or an episode of sexual abuse. If the child is handled
sympathetically, bowel control is usually rapidly regained once the stress
is reduced. The primary emphasis of management, therefore, should be on
reducing stress and making the child feel safe again.
Provocative soiling
Some children’s pattern of soiling seems designed to irritate those around
them. For example, they may deliberately defecate into baths or onto
furniture, or may smear faeces on walls – subsequently denying that
they were responsible for these acts. This covert aggression is often also
evident in other aspects of these children’s relationships with parents
and siblings. Indeed, provocative soiling is usually a marker for multiple
problems in the child and family. The child commonly has additional
emotional and behavioural problems, and the family as a whole is often
severely dysfunctional, failing to meet the child’s most basic social and
emotional needs. These children and families need help on many fronts,
often from social services and education, as well as from child mental
health professionals.
Prognosis of soiling
Whatever type of soiling is involved, persistence into adulthood is very
unusual. Resolution is generally more rapid when soiling is the only
problem. The prognosis is worse when there is coexistent ADHD or when
the soiling happens at night. A chronic course seems particularly likely
when there is a poor compliance with treatment and when soiling is
accompanied by other problems: behavioural, developmental, scholastic,
family and social.
Associated psychiatric disorders
Many studies have shown that a substantial minority of children who soil
also have one or more psychiatric disorders. For example, in a nationally
representative British sample, the rate of psychiatric disorder was found
to be over 30%. What could account for this strong association? Logically,