1/43. Treatment guidelines for primary nonretentive encopresis and stool toileting refusal. Nonretentive encopresis refers to inappropriate soiling without evidence of fecal constipation and retention. This form of encopresis accounts for up to 20 percent of all cases. Characteristics include soiling accompanied by daily bowel movements that are normal in size and consistency. An organic cause for nonretentive encopresis is rarely identified. The medical assessment is usually normal, and signs of constipation are noticeably absent. A full developmental and behavioral assessment should be made to establish that the child is ready for intervention to correct encopresis and to identify any barriers to success, particularly disruptive behavior problems. Successful interventions depend on the presence of soft, comfortable bowel movements and addressing toilet refusal behavior. Daily scheduled positive toilet sits are recommended. Incentives may be used to reinforce successful defecation during these sits. A plan for management of stool withholding should be agreed on by the parents/caretakers and the family physician before intervention. ( info) |
2/43. A group treatment approach to failure to toilet train: the case of Max. toilet training is a major developmental milestone for children and parents. Accurate statistics on the prevalence of toilet-training failure do not exist; however, it is estimated that approximately 4% of 4-year-olds are not bowel trained. A number of biopsychosocial and developmental factors can interfere with toilet training. Frequently, a cycle of withholding and constipation with painful bowel movements and/or overflow incontinence ensues. A case study of a 4-year-old boy with encopresis and pervasive developmental disorder will highlight an interdisciplinary team's approach to helping children (4-6 years old) toilet train. Along with individual patient care management, parents and children attended (separately) a six-session medical and psychoeducational group called "Toilet School." This group model employs the principles of behavior modification, the concepts of children's preoperational thinking, and a philosophy of care that values collaborative relationships between caregivers and families. ( info) |
3/43. Management of encopresis in early adolescence in a medical-psychiatric unit. The aim of this work is to present the role of a medical-psychiatric unit in the treatment of chronic resistant encopresis in adolescence as an effective alternative to the standard approach. Four case reports are presented. The integrative program is based on full patient cooperation and involves separating the patient from the family environment and the use of medical intervention combined with modified behavioral therapy and parental education and guidance. The patient is given full responsibility for the cure. The median full hospital stay for our patients was 2 weeks, and outcome in all cases was complete remission. This experience suggests that chronic resistant encopresis in adolescents requires a different approach from the standard because of the patient's developmental stage and the often hostile family dynamics. A medical-psychiatric setting provides an excellent management milieu and can lead to a dramatic improvement in this chronic disabling condition. ( info) |
4/43. The boy in the iron mask: superego issues in the analysis of a two-year-old encopretic. The paucity of psychoanalytic literature on encopresis is surprising given its frequency as a presenting symptom. Vignettes from the analysis of a two-year-old encopretic boy are presented to demonstrate the prominence of superego determinants, even in a child so young. The implications of this finding for understanding encopresis are subsequently discussed, including the common feature of depression. Technical issues arising from a sensitivity to these superego contributors are demonstrated, and the importance of addressing a child's sadistic superego directly in order to facilitate insight is emphasized. ( info) |
5/43. The reduction of soiling behaviour in an 11-year-old boy with the parent as therapist. An 11-year-old boy who had soiled daily for six years since entering school had threatened to commit suicide. Following an initial assessment, a parent was trained to monitor an experimental procedure that effectively reduced soiling to a level where the only occurrence noted in two months resulted from a bout of diarrhoea. ( info) |
| Current pediatric and psychiatric studies on encopresis and its treatment are heavily influenced by mechanical, physiological, and behavioral considerations. Although psychodynamic treatment has generally been considered to be of little benefit, and its findings suspect, the authors suggest that a psychodynamic approach adds substantially to the understanding of some cases of encopresis; that the anal sensations and anal erotic feelings reported by a number of encopretic children are intense, and that the encopretic symptom, soiling, in these children is the result of a conscious form of anal masturbation in which the fecal mass is used for stimulation; and that any study of encopresis is incomplete that does not include what encopretic children, engaged in a sound therapeutic relationship, know and say about their soiling. The authors further suggest that physical treatments of those children whose encopresis is psychologically driven may be contraindicated. The presence of a large stool does not in itself substantiate a physical illness. Further research is needed to elucidate the prevalence of anal masturbation in encopretic children. ( info) |
7/43. life-threatening respiratory failure following accidental infusion of polyethylene glycol electrolyte solution into the lung. Functional fecal retention is the most common cause of encopresis in children. hospitalization may be required to clear the bowel following failure of outpatient management. Although the safety and efficacy of polyethylene glycol electrolyte solution is well established in children older than 6 months (1), its use should be carefully monitored in patients with altered mental status or impaired airway protective reflexes. We report the accidental infusion of NuLytely into the lungs of an 11-year-old female patient who consequently developed life-threatening acute lung injury. She rapidly developed respiratory failure requiring emergent tracheal intubation and suctioning, followed by mechanical ventilation. Careful monitoring is needed to avoid this potential complication if polyethylene glycol solution is infused via a nasogastric tube. ( info) |
8/43. Little orphan Anastasia. The analysis of an adopted Russian girl. It is becoming commonplace for analysts to hear about or encounter in their clinical work adopted children from korea, china, Eastern europe, or russia. There is wide variation in the orphanage experience from one area to another and also in the manner in which the transitional phase from orphanage to adoptive parents is carried out. Not surprisingly, the experience of being an orphan carries with it lifelong implications and repercussions, particularly in the area of self/object relations. Some of the problems of being an orphan are obvious at the time of adoption. Others unfold only in the course of subsequent development. We are increasingly called upon to assist adoptive families whose children are struggling amid much pain and confusion with the aftermath of the threefold experience of becoming an orphan, being raised in an orphanage, and joining a family of another culture. This essay describes in some detail the infancy and early childhood of "Little Orphan Anastasia" as she picks through the emotional rubble of her infancy and samples the embarrassment of rich nurture in her current life with her adoptive parents, the Carters. This is followed by a description of the opening phase of her analysis, in which I sketch some of her attempts to fashion an adapted identity that is more congruent with her life before and after her adoption. ( info) |
9/43. Playful metaphors. The inner world of the child is a community of archetypes potentially available for the child's healthy ego development. Many forces limit and prohibit their utility. play therapy in the context of a hypnotic relationship can potentiate these archetypes into becoming "playful metaphors" for healing and strengthening ego development. In this article, the author describes her use of playful metaphors in her therapeutic work with two children and explores how metaphor in play therapy is able to connect the child with healing archetypal imagery. ( info) |
| This paper discusses the common cognitive features characterizing children's most frequently referred problems, with an emphasis on the difficulties' prevalence, gender ratio, and family incidence. The efficacy of cognitive treatments is examined in terms of dropping-out, regression, and generalization. In view of Piaget's notion on the concrete thinking of children, it is suggested that cognitive therapy be adopted for children by translating abstract, holistic concepts into concrete examples and by relating to day-to-day events which children can use, relate to and understand. Two cases studies are presented to illustrate the cognitive therapeutic process with young children. ( info) |