DS 9 soiling: Behavioural?

[ForMellowGreyOrca]

I originally posted this in child’s health but didn’t get any responses so have posted here as well.

Oldest dc who will be ten next week is having soiling problems. He was slow with potty training (he still isn’t dry at night as well) and always had the odd accident since his younger years where he would get caught up in his activity and leave it too late but nothing out off the ordinary so I assumed he would grow out of it. However around a year ago it started to happen a lot more frequently when now it’s happening multiple times a week at home school, and out and about where he soiled himself at the cinema a few days ago, despite him being adamant he didn’t need to go before.
I spoke with Eric on the helpline a while ago, who explained it was caused by constipation leading to an overflow and to see a GP which we did. GP seemed sure he was constipated and prescribed him Movicol, which we used for a few months and increased the strength but did absolutely nothing! He’s since had blood tests and X-rays all of which have been inconclusive to a cause, where we are directed from referral to referral without any results.
I really am fed up with it and sick to death with the laundry as it isn’t just little smears or ‘skid marks’, but it’s often full on accidents. I am constantly finding dirty underwear hidden around his room and sometimes after even after it’s very clear it’s happened from the smell he will deny it getting very defensive, until I force him to go the bathroom to change. I never imagined having to deal with this at his age especially when dd (5) is completely clean and dry at night as well. My sister mentioned to me it could be behaviourally linked which I wasn’t sure about, but really am unsure on next steps to take.
If anyone has experienced anything similar or hase any advice it would be a bloody godsend.

It is constipation and you have to use movicol long term, stopping after a couple of weeks isn't clearing the blockage.

As for advice, get a washable reusable swim nappy and have him wear it instead of underwear, it will contain the mess

How's family life? Did anything change a year ago when the soiling started to get worse? Any concerns about his mental health / emotional wellbeing? How's he doing socially at school etc?

It really will not be behavioural. It's chronic constipation..probably impacted and will need more than a couple of sachets to get it cleared.How many sachets a say was he on? One or two isn't going to cut it... impaction dose is up to 12 sachets day, and starting dose up top 4 for chronic constipation.
When the bowel is overfull it a) leaks round it..hence soiling b) loses sensation ..hence full accidents.
He needs to be taking a LOT and for a long time, both to clear the bowel and to allow the bowel to recover and literally shirnk back. It's a long game.. often years not a couple of months.

At school he needs to be encouraged to go whenever he needs to and not wait. Schools discourage children from leaving class, not surprisingly, but this is a medical issue regardless of your referral for it. So you must must impress on him and his teachers that he does not have to hold on but must immediately be allowed to access a toilet.

By behavioural do you mean linked with a SEN? It can be linked with low muscle tone sensory issues /proprioception and sometimes dyspraxia or Asperger's. My son experienced this up until the age of ten. Then it did improve. Apple juice or orange juice made it worse. You can Google "salicyiates" and their impact.
Exercise helps becoming more aware of bodily sensation hunger thirst tiredness. Some children block sensations out like "needing to go" and over time they literally lose the ability to judge.
It is not conscious thought. You can't give consequences for it
Positive Management is the key.

Hi OP

It’s obviously affecting you and your child negatively; you are feeling frustrated and he seems to feel ashamed, hence the hiding of his underwear.

I agree that Movicol should be maintained, although it may be worth a further conversation with your GP about trying a different brand/strength.

I would also consider being ‘up close and personal’ with his toileting! How much time does he sit on the loo? Can you be there and talk to him about what a bowel movement feels like while he sits there, and discuss how his bowel is feeling? Can you build an extra toilet session into his morning and evening routines, to increase his chances of passing a stool while on the loo? He is not experiencing the usual sensations of having bowel movements sitting on the loo, which are not the same as having accidents in your pants. He probably needs to be more familiar with that feeling.

To help him with a bit of positive action with this, can he start choosing a small extra portion of veg/fruit daily, to see if he, himself, can improve his bowel function (along with Movicol).

Finally, can the school help? I used to supervise a boy with a similar problem; he used to walk down to a different toilet block (not the year group) with a TA 5 or so minutes before break and have a good sit while she waited outside. She would tap on the door when time was up so that it wasn’t just a quick visit!

Don’t know if any of this is helpful, but I hope you’re able to get it sorted.

Watching TV, cinema, sitting still, computer are the worst things to do whilst you are relearning to recognise those sensations. Take the pressure off social outings, keep him near home and near clothes change/toilet but exercise and activity, loads of water not juice, work out what is likely time for accidents, plan to be in right place, near a loo before accident hits.
HTH. It will get better but do investigate sensory issues. OT assessment?

You can ask for a referral to a local encopresis service. I think the fact your ds is hiding his soiled clothes shows he is ashamed or worried about your reaction. Children of primary school age know that it is embarrassing to have toilet accidents, so it’s unlikely to be a choice. It is very very hard for a child who is constipated to get out of the cycle, and movicol is effective if it’s used to clear the blockage then maintain regular bowel movements.

Hasn’t been any changes that I can think of in the last year. He’s not the most social type and does spend a lot of time on his play station. He does have two very close friends with similar interests who's he’s known since nursery.

It took years of movicol to eventually sort my DDs impacted constipation. This is a is very long game. It takes time to clear the blockage, then to get the right level to maintain normal function. You also need routine, one of the things that really helped after getting the blockage sorted was always going to the toilet 20 minutes after breakfast and sitting for a good 15 minutes with a book or iPad. Invariably a bowel movement would happen.

I was convinced it was a behavioural issue for years. I was completely wrong. DD had issues from the get go - pooed in her nappies at night, had silent reflux as a baby. Wasn't reliably dry at night until about 12. Her bowel issues impacted on her bladder too. UTIs were common. Once the bowel was sorted her bladder wasn't irritable and she functions normally now.

If I could go back and give myself some advice it would be to be patient, buy a mountain of pants, and never show my frustration to DD.

Have you seen a specialist continence nurse? GP's are not very knowledgeable about chronic constipation unfortunately.

DC might need more than just movicol. You need to clear the bowel out completely with the increasing doses of movicol but then you need to find a maintenance dose. There are different drugs for this stage which include movicol but also sodium picosulfate and senna. They do different things.

Sodium picosulfate was a game changer for us.

DC needs structured toilet time sits, regular drinking water and over time it can be managed but honestly we went through every gp in the practice before we found one who had actual knowledge of what they were prescribing. All spoke with confidence. 3 of the 4 we saw may as well have been making it up as they went along they were so useless.

It's not behavioural and will be awful for the dc as well. Good luck with it all

You poor DS, soiling yourself at nearly 10 has got to be really distressing. Please be understanding and kind about this. He's obviously already ashamed as he's hiding his underwear. This is major mental health issues just waiting to happen IMO if you are not handling it really sensitively and as a medical issue not something he should be punished/shamed for.

He does have a toilet pass at school and is allowed to go whenever he needs to.
He has been tested for SEN when he was younger, but I meant more that sometimes he will still try and hold it in if he is playing or watching TV often leading to accidents, which I wasn’t sure was linked to constipation or not.

Hi, I will definitely speak to the GP about a different brand of Movical or potentially a different type of laxative?
We have been doing scheduling toilet sittings with a varying level of a success. He hates being made to sit on the toilet and takes a lot of persuading as he will say he doesn’t feel the need. Will persevere with him on this.
With regards to the school, the nurse is aware of his problem hence he is allowed to use the loo during lessons. Would I need to a referral from a GP to organise a TA helping him out?

@Nettleskeins What do you mean by OT assement and sensory issues? Thanks

I was told apples and pears (4 per day!) and plenty of water after sorting the immediate problem out with Movicol.
For my nephew, the issue was exacerbated by his gaming as he didn't want to break to gk tk the loo.

Hi OP

Yes, I expect he does hate it - not sure I’d be thrilled myself!

Are you the sort who could sit with him and have a chat? Or read a book to him or something? Not the most comfortable situation, but it can help to relieve tension - or will your presence make the tension worse?!

I don’t know if a GP letter would help or not. The child I had was from a neglectful family and this was the school’s attempt to try and help - but this was in an area of high deprivation where we went the extra mile. It was also about 10 years ago, when TAs weren’t needed in the class as much.

Can you discuss the options with your son? He might be horrified at the thought of having accompanied toilet visits in school and so consent to extra toileting at home - without the persuading!

I’m sure you’ll get on top of it eventually.

Hi, thanks for the advice. We are still working on establishing a routine, but he as I said he hates sitting on the loo, and when he does is always rushing to finish so he get back to his game!
It can be very frustrating especially when I know he is sometimes being lazy. He’s had quite a few instances of soiling himself while on his play station even after I’ve made him sit on the loo a few minutes before. Last week I went downstairs in the morning and he was watching TV, still in his nighttime pull up with it being evident he had used it again! But as you say I am definitely trying to maintain patience with him as I know sometimes he can’t help it, and we are in it together. I never would of thought I would still be wiping his bottom age 9 but life is full of surprises!

DD hated sitting on the loo too. I had to let her play games on the iPad so she'd sit for longer than a couple of minutes. Also sitting on the loo after a bath helped too.

I got so frustrated with similar behaviours to those you describe. He really isn't lazy. He can't feel himself pooing due to the impaction. He won't be feeling the urge like we do.

Hang in there, it will get better. Good luck to you and your DS.

Hi OP, does sound like chronic constipation. There's a fab video on YouTube called 'the poo nurses' where they explain it really well including how to use Movicol correctly.

I do often insist of coming into the toilet with him but he will almost always demand I leave to give him privacy. I will try to talk to him about me being in there to read to him, although I doubt it will change anything, as he would likely find it degrading. As you say he would be in fits about having supervised toilet visits at school so don’t know if it’s the right option.

Appreciate your comment, but I have never or will ever punish him for it. I know the toll it takes on him and will always support him through it. However sometimes I firmer approach is definitely needed when I know his accidents are sometimes caused by laziness

You are ignoring the posters telling you it's not laziness, your child has chronic constipation and it's going to start making him wet too.

There's a really good video called The Poo in You that explains it. Watch it and let him watch it too (separately if he's embarassed). Sit him on the loo with a gaming device after each meal. Both of these have been game changers for one of my dc. Also serving tinned peaches and similar for pudding, and lots of high fibre, high water-content food. Offering more tempting drinks. The regular toilet time made a huge, huge difference.

OT stands for occupational therapist. Ask Dr for a referral to an OT. Private if you can afford it and don't want to wait. This soiling issue will be affecting his social life and his confidence.

Also try to get him away from the play station ...an OT might recommend beneficial activities to boost his confidence and engagement, even Lego would be better or Chess or listening to music. It's very very distracting and won't be helping him concentrate or notice what is going on with his digestion etc.

I wouldn't be suggesting accompanying him to the loo or supervised toileting in school just that he needs to know someone will listen and let him go, if he feels he has to go. In my son's day it was called a "toilet pass". Obviously with only a few teachers in primary they could all be on board. They are trained to hold on or not speak out in school from Year 1 at least. It's difficult to rewire putting up your hand and a teacher letting you leave class.

They being the children!