JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2017, 50, 332–344 NUMBER 2 (SPRING)

A MULTIDISCIPLINARY TREATMENT FOR ENCOPRESIS

IN CHILDREN WITH DEVELOPMENTAL DISABILITIES
NATHAN A. CALL AND JOANNA LOMAS MEVERS
MARCUS AUTISM CENTER, CHILDREN’S HEALTHCARE OF ATLANTA
EMORY UNIVERSITY SCHOOL OF MEDICINE

BARBARA O. MCELHANON
EMORY UNIVERSITY SCHOOL OF MEDICINE

AND

MINDY C. SCHEITHAUER
MARCUS AUTISM CENTER, CHILDREN’S HEALTHCARE OF ATLANTA
EMORY UNIVERSITY SCHOOL OF MEDICINE

Achieving continence of one’s bowel movements is a key step in development and failure to do so
leads to many negative consequences. Treatments for encopresis appearing in the literature have
employed behavioral strategies; medications such as suppositories, laxatives, or enemas; and in
some studies a combination of these approaches. To date, attempts to extend successful treatments
for encopresis in typically developing children to those with developmental disabilities have been
limited. The current study included three participants diagnosed with developmental disabilities
who had a history of encopresis. None of the participants had a continent bowel movement under
baseline conditions. Continent bowel movements increased during treatment that included the
addition of suppositories to elicit continent bowel movements. Two participants began having
independent continent bowel movements (i.e., without requiring suppositories) and medication
was successfully faded out for the remaining participant. Treatment took between 13 and 21 days.
Key words: encopresis, medication, multidisciplinary treatment, toileting

Toilet training one’s child is a nearly univer- collected data on 102 individuals with autism
sal challenge for parents, but is a particularly and reported that over 59% had not achieved
distressing ordeal for many parents of children bladder or bowel continence by 3.5 years of
with developmental disabilities. Whereas typi- age. Toileting concerns are a significant con-
cally developing children generally stop having tributor to the increased stress experienced by
daytime toileting accidents (i.e., they achieve caregivers of those with developmental disabil-
continence) by 2 to 4 years of age (Blum, ities (Macias, Roberts, Saylor, & Fussell, 2006).
Taubman, & Nemeth, 2003; Butler, 1997; Besides dramatically increasing the burden of
Heron, Joinson, Croudace, & von Gontard, caring for an individual with developmental
2008; Schum et al., 2002; Tsai, Stewart, & disabilities, not being fully toilet trained nega-
August, 1981), most individuals with develop- tively impacts the individual’s hygiene, physical
mental disabilities are either delayed in their comfort, and independence, and causes social
acquisition of toileting skills or never achieve stigma (Cicero & Pfadt, 2002; Sells-Love,
continence. For example, Tsai et al. (1981) Rinaldi, & McLaughlin, 2002). Incontinence
can also have serious collateral consequences,
Please address correspondence to: Nathan A. Call, such as limited exposure to important life
1920 Briarcliff Rd., Atlanta, GA 30329. E-mail: Nathan.
call@choa.org
experiences. For example, many educational or
doi: 10.1002/jaba.379 childcare settings will not enroll a child who is
© 2017 Society for the Experimental Analysis of Behavior
332
 TREATMENT FOR ENCOPRESIS 333

not fully continent. Thus, despite the current colon accommodates the fecal mass and the urge
emphasis on the importance of inclusion of to defecate is delayed. The postponed bowel
children with developmental disabilities with movement allows more water to be absorbed
their typically developing peers (Dempsey, from the colon and creates a harder stool. Over
2005), a lack of continence is a significant bar- time the colon adapts by dilating, which leads to
rier to achieving this goal. Furthermore, with- larger fecal masses in the rectum. Thus, the pas-
out effective treatment, these problems sage of larger and harder (i.e., painful) stools is
generally persist into adulthood (Benninga, likely to further punish moving one’s bowels and
Voskuijl, & Taminiau, 2004). negatively reinforce the individual’s avoidance of
Current approaches to toilet training indivi- bowel movements. Of note, 63% of children
duals with developmental disabilities have with encopresis have a history of painful defeca-
mainly focused on using behavioral strategies to tion beginning before 36 months of age
treat enuresis (Azrin, Bugle, & O’Brien, 1971; (Lewis & Rudolph, 1997). Over time, the rec-
Azrin & Foxx, 1971; Lancioni & Markus, tum and colon become dilated such that some
1999; Richmond, 1983; Sells-Love et al., 2002; individuals lose the sensation that typically serves
Wilder, Higbee, Williams, & Nachtwey, as a motivating operation (MO; Laraway, Sny-
1997). Although these approaches have gener- cerski, Michael & Poling, 2003) for having a
ally been shown to be successful at establishing bowel movement. Looser stool may seep around
urinary continence (LeBlanc, Carr, Crossett, hard stool leading to leakage and sometimes
Bennett, & Detweiler, 2005), there are far large evacuations of feces.
fewer successful demonstrations of strictly Although purely medical approaches can suc-
behavioral treatments for encopresis in indivi- cessfully treat constipation in individuals with
duals with developmental disabilities. One rea- developmental disabilities, they have not shown
son for the discrepancy between outcomes for long-term success with encopresis. That is,
behavioral interventions for enuresis and enco- medical approaches can treat a single episode of
presis may be that the latter may frequently constipation, but without acquiring toileting
have a medical etiology. That is, children who skills, the individual is likely to become consti-
exhibit encopresis often have a lengthy history pated again, repeating the cycle (Furuta et al.,
of constipation, which may contribute to its 2012). However, there is evidence that a multi-
occurrence (Chase, Homsy, Siggaard, Sit, & disciplinary approach that incorporates both
Bower, 2004; Koivusalo, Pakarinen & Rintala, medical and behavioral approaches to the treat-
2006; Mason, Tobias, Lutkenhoff, Stoops, & ment of encopresis can successfully resolve
Ferguson, 2004). In particular, children with encopresis in typically developing individuals
developmental disabilities such as autism spec- (Friman, 2008; Friman, Hofstadter, & Jones,
trum disorder (ASD) are 3.8 times more likely 2006). Within this model, medical approaches
to have constipation than typically developing are employed to resolve episodes of constipa-
children (McElhanon, McCracken, Karpen, & tion prior to treatment and provide a regimen
Sharp, 2014). that increases the predictability of a bowel
Constipation is thought to cause encopresis movement. Increased predictability of a bowel
by creating a cycle of negative reinforcement and movement in turn allows behavioral clinicians
punishment in which it causes bowel move- to prompt sitting on the toilet beforehand.
ments to be painful, which in turn serves to pun- Once a continent bowel movement occurs it is
ish having a bowel movement (Fishman, then amenable to positive reinforcement.
Rappaport, Cousineau, & Nurko, 2002), result- Although there is significant empirical sup-
ing in worsening constipation. Subsequently, the port for such a multidisciplinary approach to
334 NATHAN A. CALL et al.

the treatment of encopresis in typically devel- movement. If the child did not have a bowel
oping individuals, there is less evidence of the movement, or if the bowel movement was
success of these treatments with individuals small, then a suppository was administered.
with developmental disabilities. Furthermore, Continent bowel movements resulted in care-
published examples of these treatments gener- giver attention, whereas reprimands and posi-
ally include components that may be inappro- tive practice were delivered contingent on
priate or unfeasible for some individuals with incontinent bowel movements. Two of the four
developmental disabilities. For example, several participants also required the addition of other
studies recommend counseling the individual punishment procedures in the form of
in an effort to demystify the toileting process increased positive practice trials and a 5- min
(Levine, 1982), showing the child a diagram of timeout contingent upon incontinence. Suppo-
abnormal bowel functioning (Boon & Singh, sitories were eventually faded out over a num-
1991), and having them observe another per- ber of weeks, with all four participants
son demonstrate the “Valsalva maneuver” maintaining independent continent bowel
(i.e., grunting push; Cox, Sutphen, Ling, movements.
Quillian, & Borowitz, 1996). Unfortunately, Although these and a few other studies
many individuals with developmental disabil- report successful treatment of encopresis in
ities may lack the cognitive ability or behavioral individuals with developmental disabilities, all
repertoire to benefit from these treatment com- suffer from potentially significant limitations.
ponents. Many multidisciplinary treatments for For example, in the study by O’Brien
encopresis also recommend making dietary et al. (1986), treatment took between 6 and
changes, such as increasing dietary fiber (Stark, 35 weeks and only one of the participants had
Owens-Stively, Spirito, Lewis, & Guevremont, a developmental disability. Others included
1990; Williams, Bollella, & Wynder, 1995). only a single participant (e.g., Jansson, Dia-
However, children with some developmental mond, & Demb, 1992; Smith, 1994), and
disabilities, such as ASD, are at increased risk most employed weak experimental designs
for food selectivity that may limit fiber intake (Lancioni & Markus, 1999). Many of these
(Sharp et al., 2013). Finally, existing treatments existing studies also fail to provide important
for encopresis in typically developing children procedural details or outcome measures, or
generally require a level of compliance that included participants with and without disabil-
some children with developmental disabilities ities (e.g., O’Brien et al.). Several relied upon
may be unlikely to exhibit. the use of enemas and punishment for inconti-
Thus, despite evidence supporting the effec- nence (e.g., O’Brien et al.; Piazza, Fisher,
tiveness of multidisciplinary approaches to the Chinn, & Bowman, 1991), which may be less
treatment of encopresis in typically developing acceptable to caregivers. Perhaps most limiting,
individuals, only a small number of studies the majority of published examples of the suc-
report successful treatment of encopresis in cessful treatment of encopresis have required
individuals with developmental disabilities implementation over long periods, with dura-
(Lancioni, O’Reilly, & Basili, 2001). In one of tions from 6 to 98 weeks (e.g., Smith, 1994,
the few published examples, O’Brien, Ross, 1996). These limitations may contribute to the
and Christophersen (1986) treated encopresis fact that encopresis generally remains untreated
in four boys, ages 4 to 5. Treatment included in most individuals with developmental
the use of an enema in the morning, followed disabilities.
by a 5-min toileting sit to provide an opportu- The present study evaluated a combined
nity for an independent continent bowel behavioral and medical regimen to treat
 TREATMENT FOR ENCOPRESIS 335

encopresis in three participants with develop- the same clinic-based program as Albert. How-
mental disabilities. Given some of the inconsis- ever, all of his bowel movements were inconti-
tencies and limitations in the existing literature nent, so he wore sanitary undergarments.
cited above (Klassen et al., 2006), a central pur- Braydon also had a history of constipation. At
pose of this study was to resolve some lingering the time of his participation, he was taking Tri-
questions by ensuring that: (a) all three partici- leptil for seizures, which were well controlled
pants were diagnosed with developmental dis- by the medication.
abilities; (b) the only medication included Max was an 8-year-old boy diagnosed with
consisted of over-the-counter suppositories; developmental delay and expressive language
(c) treatment effects were evaluated within a disorder. He communicated vocally in com-
commonly used experimental design plete sentences and could follow most spoken
(i.e., multiple baseline across participants); directions. The majority of his urinations were
(d) the speed with which treatment effects continent, and he sometimes initiated trips to
occurred was considered a priority; and the bathroom to urinate. However, Max would
(e) reports of maintenance in the natural envi- not initiate trips to the bathroom to have a
ronment were collected from primary caregivers. bowel movement. He would often go several
days without having any bowel movements,
and when he did have a bowel movement, it
METHOD
was almost always incontinent. Max did not
Participants & Setting receive formal toilet training prior to his partici-
Three children, each of whom were referred pation in the study.
to an intensive outpatient clinic for encopresis, The outpatient clinic where the study was
served as participants. Albert was an 8-year-old conducted provided a range of treatment ser-
boy diagnosed with ASD who used single vices for individuals with developmental dis-
words, sign language, and a picture exchange abilities, including toilet training. Treatment
system to communicate. He maintained urinary sessions were conducted in individual bath-
continence through frequent (approximately rooms that contained a toilet, sink, mirror,
hourly) caregiver-initiated trips to the bath- trash receptacle, and other necessary materials
room, but did not initiate bathroom trips him- (e.g., toilet paper, cleaning supplies). When
self. Albert previously received treatment for participants were not actively engaged in treat-
urinary incontinence in a clinic-based enuresis ment procedures (e.g., before treatment and
program that employed procedures similar to between scheduled sits), they remained in a
those described by Azrin and Foxx (1971) and playroom that was either adjoining or across a
LeBlanc et al. (2005). However, he continued hallway from the bathroom.
to wear sanitary undergarments because almost Prior to participating, each participant was
all of his bowel movements were incontinent. required to undergo screening by a pediatric
Braydon was an 8-year-old boy diagnosed gastroenterologist to receive medical clearance
with ASD and an intellectual disability of to participate. As part of this examination,
unspecified level. He had never spoken, but each participant was assessed for medical
could imitate motor movements, receptively causes of encopresis (e.g., spinal cord abnor-
identify many items, and follow both simple mality) and for constipation. Medical treat-
and complex instructions (e.g., come down- ment was completed (i.e., stool softeners)
stairs, put your plate in the sink, and then pick to resolve any constipation prior to
up your toys). He had previously received suc- completing the combined behavioral and
cessful treatment for urinary incontinence in medical treatment protocol. The pediatric
336 NATHAN A. CALL et al.

gastroenterologist also provided medical include parent-collected data from participants’

approval for the use of over-the-counter medi- homes and therapist-collected data from the
cations that were part of the protocol clinic setting. All of the participants were under
(i.e., glycerin and bisacodyl suppositories). the direct care of their primary caregivers or
clinic staff throughout their participation (they
Experimental Design, Response did not attend school during treatment), so data
Measurement, & Interobserver Agreement were always collected through direct observation
Data were collected within a nonconcurrent or by recording permanent product of a bowel
multiple-baseline-across-participants design. movement (i.e., finding the participant in soiled
Continent and incontinent bowel movements underwear). Because it was technically possible,
served as the primary dependent variables for this although highly unlikely, for a caregiver to fail
study. A continent bowel movement was defined to detect an incontinent bowel movement
as any defecation that occurred while the partici- shortly after it occurred, it was theoretically pos-
pant sat on a toilet (i.e., both buttocks resting on sible for a participant to have multiple inconti-
the toilet seat). An incontinent bowel movement nent bowel movements that were counted as a
was defined as any defecation that occurred while single incontinent bowel movement. It was also
the participant was not seated on the toilet. The possible for a continent bowel movement to go
data collector also recorded whether medication unnoticed by a caregiver if the participant used
was used to elicit a bowel movement, and if so, the bathroom independently; however, this too
the number of doses and type of medication. If was highly unlikely, as all of the participants
no medication was used the data collector scored had long histories of incontinence and no history
the bowel movement as independent. Finally, of independently completing toileting and
data were also collected on the number of times hygiene tasks. Interobserver agreement data were
participants sat on the toilet and the duration of collected in the clinic by a second observer who
each sit for the purpose of ensuring procedural simultaneously, but independently, recorded the
fidelity. occurrence of continent or incontinent bowel
Data were recorded using paper datasheets by movements. Agreement data were collected dur-
making a tally mark in one of two columns ing 37% of scheduled sits for Albert, 40% of
(“incontinent” and “continent”) to denote the scheduled sits for Brayden, and 43% of sched-
type of bowel movement. In addition, the per- uled sits for Max. It was not possible to collect
son collecting data recorded whether the interobserver agreement data in the home setting;
bowel movement occurred independently however, interobserver agreement for continent
(i.e., without the use of medication) or follow- and incontinent bowel movements averaged
ing a 1st or 2nd dose of medication. The data- 100% across participants in the clinic.
sheet had two columns for each day, and
enough space to record data on bowel move- Procedures
ments for one week. Data were collected by General procedures. Although data were col-
trained clinical staff. Because it was possible for lected on bowel movements that occurred in
bowel movements to occur outside of clinic the clinic and home settings, treatment proce-
time, participants’ primary caregivers were dures were initially conducted only in the clinic
trained to use the same data collection system to setting. During baseline and initial treatment
record continence and incontinence of bowel phases, caregivers were instructed to follow
movements during times participants were in their normal toileting routine and procedures
settings other than the clinic. Thus, figures in the home. However, at the conclusion of
 TREATMENT FOR ENCOPRESIS 337

treatment in the clinic, at least one of each par- reinforcement. Participants then received
ticipant’s caregivers was trained to implement enthusiastic praise along with 3 min access to
treatment procedures. the preferred item and one portion of an edible
Baseline. Participants’ daily visits to the clinic item (Albert and Braydon only). Once the rein-
lasted for up to 4 hr. Clinic visits ended when forcement interval ended, the therapist
the participant had a continent bowel move- prompted the child to wash his hands using a
ment or following the last toileting sit of the least-to-most prompting procedure, after which
day. Upon arrival, therapists changed partici- they exited the bathroom.
pants who were wearing sanitary undergar- Although it never occurred, had the partici-
ments into cloth underwear. The therapist then pant begun to defecate or urinate during a
conducted a multiple stimulus without replace- scheduled off-the-toilet interval (i.e., between
ment (MSWO; DeLeon & Iwata, 1996) prefer- medication administrations [see below] or the
ence assessment to identify a preferred edible or 1 min of scheduled standing between 10 min
leisure item that was to be delivered contingent of sitting), the therapist would have immedi-
upon continent bowel movements, if one ately guided the child to sit on the toilet until
occurred. the completion of the bowel movement. If a
Clinic visits consisted of a series of scheduled bowel movement began during one of these
sits, which lasted for up to 60 cumulative min intervals but resulted in meeting the definition
on the toilet and were interspersed with 30- of a continent bowel movement following
min breaks. Each sit consisted of cycles of prompting to sit on the toilet (i.e., feces was
10 min with both buttocks on the toilet, fol- deposited only in the toilet), it would have
lowed by 1 min of standing. For the first sit of been counted as a continent bowel movement
the day, the cycle repeated six times for 66 total and the corresponding contingencies would
min (i.e., 60 min sitting and 6 min standing). have been implemented. Because each partici-
Any sits that took place after the first sit pant’s caregivers reported that their child still
included three cycles of sitting and standing for had at least occasional incontinent urinations,
a total of 33 min. The inclusion of 1 min of the therapist delivered praise following any con-
standing was devised to ensure that there was tinent urination.
sufficient blood circulation to participants’ legs. Treatment. During treatment, clinic visits
In addition, at the suggestion of the third and instructions to caregivers regarding partici-
author, who is a pediatric gastroenterologist, pants’ toileting routine outside of clinic visits
participants’ feet were supported during sits. were identical to the baseline condition with
That is, they were either able to rest their feet the following exceptions: If an independent
flat on the floor or on a stool that was provided continent bowel movement did not occur dur-
in front of the toilet. If at any time during the ing the initial 60-min sit, participants received
10-min sit interval the participant removed a 5-min break off of the toilet but remained in
their buttock from the toilet, they were imme- the bathroom without access to preferred items
diately prompted to sit back down using a or more attention than was necessary to imple-
least-to-most-prompting procedure. ment the procedures. Following the 5-min
Following any continent bowel movements, break, nursing staff administered a liquid glyc-
the participant remained on the toilet for 10 s erin suppository, which attracts water into the
to ensure the bowel movement had been com- rectum to gently promote a bowel movement.
pleted. The therapist then quickly assisted the Dosing of all suppositories was determined by
child in completing necessary hygiene tasks and the third author and consisted of 7.5ml (Fleet
dressing in an effort to avoid delaying Adult Liquid suppositories). Therapists
338 NATHAN A. CALL et al.

prompted participants to complete a 30-min sit suppository was necessary. Shortly after Bray-
(interspersed with 1 min of standing every den began having more consistent continent
10 min) immediately after receiving the glyc- bowel movements with the use of the glycerin
erin suppository. If a continent bowel move- suppository, he also started having independent
ment did not occur during the 30-min sit that continent bowel movements during the first
took place after administration of the glycerin scheduled sit. Thus, there was no need to
suppository, the participant received a 30-min implement medication fading.
break, after which nursing staff administered a Follow-up phone calls. Each participant’s care-
second glycerin suppository. For Brayden, a giver was contacted, by phone, 1 month follow-
bisacodyl suppository (Dulcolax 10 mg) was ing discharge to evaluate if their child had
initially administered as the second suppository. maintained the gains made during the treat-
Bisacodyl suppositories differ from glycerin in ment program. Caregivers were asked the fol-
that they directly stimulate sensory nerves and lowing questions: (a) “Is your child remaining
amplify peristaltic contractions. However, use continent?”, (b) “How often is your child hav-
of this medication was discontinued following ing accidents?”, (c) “Does your child self-
day 11, because the bisacodyl only resulted in a initiate when they need to have a bowel move-
continent bowel movement once (day 11) and ment?”, and, (d) “Are you still implementing
caregivers reported that Brayden was experien- the treatment recommendations?”
cing abdominal cramping several hours follow-
ing administration. At this point, a second
glycerin suppository was administered if a con- RESULTS
tinent bowel movement did not occur follow- Albert did not have any continent or incon-
ing the independent sit and first administration tinent bowel movements during baseline (see
of glycerin. Following administration of the Figure 1). Once treatment was implemented,
second suppository (glycerin or bisacodyl), the Albert had one continent bowel movement
therapist prompted the participant to complete each day with the exception of day 14, on
another 30-min sit. If a continent bowel move- which he had two. He also had a single inconti-
ment did not occur during the 30-min sit that nent bowel movement on days 5 and 13.
took place after administration of the second Continent bowel movements occurred follow-
suppository, the clinic visit ended. ing a single glycerin suppository on days 4 and
Medication fading. For Albert, the treatment 5 (see Figure 2). The medication fading regi-
protocol included medication fading. That is, men began on day 6 with a half dose success-
the dose of medication decreased by 50% each fully producing a continent bowel movement
time Albert had a continent bowel movement on days 6 and 7. A quarter dose of the glycerin
after the first suppository for 2 successive days. suppository similarly produced a continent
Fading continued until the dose was one quar- bowel movement on days 8 through 12, with
ter of the original. If at any point continent the exception of day 11 when a second quarter
bowel movements had not occurred for 2 con- dose of glycerin was necessary. Beginning on
secutive days, the previous step would have day 13, Albert began having independent con-
been reinstated, but this never happened. tinent bowel movements (i.e., on the first
Because Max started having independent scheduled sit, prior to administration of any
continent bowel movements (i.e., without the medication).
use of medication) consistently and without Brayden did not have any continent bowel
any incontinence on the 3rd day of treatment, movements during baseline (Figure 1),
neither medication fading nor a second daily although he had incontinent bowel movements
 TREATMENT FOR ENCOPRESIS 339

Baseline Treatment
3 Continent

No Med Incontinent

½ dose ¼ dose

0 Albert

3
Frequency of Bowel Movements

No Med

2
No Med

Brayden

3
No Med

Max
0

5 10 15 20

Days

Figure 1. Frequency of continent and incontinent bowel movements.

340 NATHAN A. CALL et al.

Independent
3
No Med 1st Dose-Glycerin
Glycerin
2nd Dose

2
½ dose ¼ dose

Albert
0

3
Frequency of Bowel Movements

No Med

2
No Med
Bisacodyl Glycerin

Brayden
0

3
No Med

Max
0

5 10 15 20
Days

Figure 2. Frequency of continent bowel movements that were independent (no medication) preceded by one dose
of medication (glycerin) or two doses of medication (glycerin or Dulcolax).
 TREATMENT FOR ENCOPRESIS 341

on the 1st, 4th, and 6th days. Brayden did not movement (i.e., on the first scheduled sit,
have a bowel movement on day 7 (i.e., the first prior to administration of any medication) and
day of treatment), and had two incontinent no incontinent bowel movements.
bowel movements on day 8. On day 9, Brayden All three participants’ caregivers reported
had his first continent bowel movement follow- during follow-up phone calls that their child
ing the administration of the glycerin supposi- remained entirely continent with the exception
tory (see Figure 2). In the next four days, the of Max, who was having one to two accidents a
only bowel movements occurred on day 11, on week. Even though Max’s mother reported that
which he had two: a very small independent he was having occasional accidents, he was also
one and one following the second suppository, having continent bowel movements, which
which was bisacodyl. Beginning on day represented an improvement from baseline.
14 Brayden began having daily continent bowel Thus, she indicated that she was pleased with
movements, either following the first (days his progress and expected further improvement
15 and 17) or second (days 14 and 16) glycerin in continence with continued implementation
suppository. He also had three additional bowel of the treatment protocol. In addition, two of
movements that were incontinent on day the three caregivers interviewed reported that
15 (see Figure 1). Two continent bowel move- their child was self-initiating trips to the bath-
ments occurred without the use of medication room that resulted in continent bowel move-
on day 18. On day 19, Brayden had an inde- ments, a behavior that was not directly targeted
pendent continent bowel movement, but it was as part of the intervention. All of the caregivers
very small. Therefore, the glycerin suppository reported that they continued to implement the
was still administered and Brayden had a sec- treatment recommendations.
ond, larger continent bowel movement follow-
ing the suppository. On day 20, Brayden began
having independent continent bowel move- DISCUSSION
ments consistently (i.e., on the first scheduled
This study attempted to ascertain the effec-
sit, prior to administration of any medication; tiveness of a multidisciplinary treatment for
see Figure 2). encopresis in individuals with developmental
Max had an incontinent bowel movement disabilities that combined the use of behavioral
on the 1st day of baseline, but no other conti- strategies in the form of preference assessments,
nent or incontinent bowel movements for the reinforcement, and fading with the use of over-
remainder of the phase (see Figure 1). On the the-counter medications to elicit a continent
1st day of treatment (i.e., day 8), Max had bowel movement. Overall, none of the partici-
one independent continent bowel movement pants had a continent bowel movement during
(see Figure 2). However, he also had two the baseline phase, and Brayden and Max had
incontinent bowel movements (see Figure 1). at least occasional incontinent bowel move-
On day 9 he had an independent continent ments. Once the intervention was instituted,
bowel movement during the first sit. However, two participants (Albert and Max) immediately
the bowel movement was very small. There- began to have consistent continent bowel
fore Max still received the first glycerin sup- movements, and the third (Brayden) did so
pository, after which he had a large continent within 8 days of the initiation of treatment.
bowel movement. For the remainder of the Furthermore, all caregivers reported that the
treatment phase (i.e., days 10-13), Max had at participants were continuing with continent
least one independent continent bowel bowl movements 1 month following discharge
342 NATHAN A. CALL et al.

and that two of the three participants were not endorsement regarding the appropriateness of
experiencing any accidents. suppositories for each potential patient prior to
The use of suppositories as outlined in this implementation. We see no reason why that
study may have advantages over other medica- recommendation would not be equally valid
tion regimens that have been incorporated into when treating individuals with developmental
treatments for encopresis in the literature. That disabilities.
is, the rapidity of bowel movements following The use of suppositories may raise some con-
administration of the medication increased the cerns regarding the invasiveness of administra-
predictability of the bowel movements, which tion. It is true that participants occasionally
in turn allowed therapists to ensure the partici- exhibited behavior suggesting that the adminis-
pants were sitting on the toilet when a bowel tration of the suppositories was aversive
movement occurred. By contrast, laxatives tend (e.g., squirming, whining). Concerns from care-
to increase the probability of a bowel move- givers regarding the invasiveness of these proce-
ment, but the latency following administration dures are likely to be a serious impediment to
may be so variable as to make it difficult to pre- positive outcomes. Thus, as with any poten-
dict the bowel movement and ensure tially aversive procedure, the use of supposi-
continence. tories must be justified by the potential benefits
The multidisciplinary nature of this treat- and a lack of alternative approaches. For these
ment for encopresis, which included the partic- participants, other rigorous toilet training
ipation of behavior analysts, a pediatric approaches had been unsuccessful. Their care-
gastroenterologist, and nursing staff, could be givers each reported that incontinence signifi-
viewed as a model for other disorders that have cantly increased the burden of caring for their
combined behavioral and medical etiologies. child, and that it placed many restrictions on
The conceptualization of encopresis as learned their ability to access some settings or reinfor-
behavior resulting from physiological stimuli cing activities (e.g., swimming). Each of these
was critical in the development of this protocol. participants’ constipation was also requiring
Involvement of medical professionals was also regular use of medications and procedures that
critical for the purposes of resolving any were equally, or potentially more, invasive or
episodes of constipation and approving admin- aversive as the suppositories included in this
istration of the suppositories prior to partici- treatment (e.g., enemas). Furthermore, these
pation. Despite the advantages of such a multi- medical alternatives had been in place for sig-
disciplinary approach, a disadvantage may be nificant periods of time and had no discernable
the fact that clinical settings without the requi- end in sight. Thus, despite its potentially aver-
site assemblage of disciplines may be unable to sive nature, the short-term use of suppositories
implement this protocol. Thus, the level and appeared to be justified for these participants.
type of clinicians necessary to conduct this pro- However, consideration of these factors will be
tocol may be a topic for future research. For important in any future applications of this
example, because the medications used are protocol. In addition, it is possible that conti-
available over-the-counter, it may be possible to nence increased due to negative reinforcement
implement the protocol with nonmedical staff in the form of avoidance of administration of
administering the suppositories. However, the suppository. Thus, the specific mechanism
accepted best practices for treating typically responsible for the treatment effect is another
developing children strongly recommend con- potential topic for future research.
sultation from a gastroenterologist to resolve Key findings of this study include the fact
any episodes of constipation and to obtain an that participants’ bowel movements became
 TREATMENT FOR ENCOPRESIS 343

continent rapidly (range, 6 to 16 days) and that Butler, R. J. (1997). Elimination disorders. In C. A. Essau
medications could be quickly eliminated. The & F. Petermann (Eds.), Developmental psychopathology:
Epidemiology, diagnostics and treatment (pp. 447–471).
slowest responder to treatment (Brayden) took Australia: Harwood Academic Publishers.
only 13 days to begin having independent con- Chase, J. W., Homsy, Y., Siggaard, C., Sit, F., &
tinent bowel movements without the use of Bower, W. F. (2004). Functional constipation in
children. The Journal of Urology, 171, 2641–2643.
medication. Relative to previous studies, some doi:10.1097/01.ju.0000109743.12526.42
of which took as long as 98 weeks to achieve Cicero, F. R., & Pfadt. A. (2002). Investigation of a
continence (Smith, 1996), this represents a dra- reinforcement-based toilet training procedure for chil-
dren with autism. Research in Developmental Disabil-
matic decrease in the time required for treat- ities, 23, 319–331. doi:10.1016/S0891-4222(02)
ment. However, with the small number of 00136-1
participants in this study, it is unclear whether Cox, D. J., Sutphen, J., Ling, W., Quillian, W., &
such rapid effects are the norm. It is also note- Borowitz, S. (1996). Additive benefits of laxative, toi-
let training, and biofeedback therapies in the treat-
worthy that the only participant who did not ment of pediatric encopresis. Journal of Pediatric
maintain continence at follow up (i.e., Max) Psychology, 21, 659–670. doi:10.1093/jpepsy/
was also the only participant who did not have 21.5.659
DeLeon, I. G., & Iwata, B. A. (1996). Evaluation of a
any continent bowel movements in the home multiple stimulus presentation format for assessing
setting during treatment, suggesting that pro- reinforcer preferences. Journal of Applied Behavior
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practices. In P. Foreman (Ed.), Inclusion in action
maintenance. Future research is necessary not (pp. 35–65). Southbank, Victoria: Thomson.
only to replicate and extend these findings, but Fishman, L., Rappaport, L., Cousineau, D., & Nurko, S.
to compare this treatment with other (2002). Early constipation and toilet training in chil-
dren with encopresis. Journal of Pediatric Gastroenter-
approaches. Given the promising nature of ology and Nutrition, 34, 385–388. doi:10.1097/
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