In this article, Angela takes a practical and resourceful approach to addressing this sensitive issue, particularly for those caring for looked-after or adopted children. Angela is a clinical psychologist with many years experience working with children. She is also the author of several books.

In my work with looked after and adopted children I am frequently asked why children soil in their underwear or other inappropriate place. This difficulty can cause big rifts between the child and the carer, who often takes the problem personally. It is especially true of the carer who wants and expects to have strong feelings of love for the child, because they see themselves as a channel of God's love to a needy, hurting child.

The first important fact to understand is that a child with a soiling difficulty is not doing it on purpose. Soiling is not an unusual problem. Research has found that three in every 100 five-year olds have soiling difficulties. By age 12 this could still be a problem for more than 1 in every 100 children. These numbers may be lower than true incidence, because people are often too embarrassed to report the problem.

Reasons why children soil

Not being able or willing to control going to the toilet in an appropriate manner can be, but is not always, the result of past abusive experiences. For example, a girl who has been sexually abused may have emotionally cut off from any bodily sensations below the waist as a defence mechanism. This has helped her cope with the unthinkable things that have happened to her. Small wonder then that she forgets to use the toilet.
Other abuse, such as regular beatings on the buttocks, can cause the same response. The child cuts off from the sensations of pain, but in so doing loses the ability to recognise body signals to go to the toilet.

Other reasons to do with being in care can lead to soiling and/or wetting. It may be that the child has never received proper toilet training because his or her birth family was too chaotic to manage it, or that the child was moving between families at the time when he or she was developmentally ready to be trained. Faced with the much larger task of surviving in a new family, the child may not have been able to focus on the new learning required to become clean.

A very common cause of soiling is constipation. Although this sounds crazy, it happens because new runny faeces have nowhere to go but to seep round the old hard faeces. The child will have absolutely no control over this seepage. Sometimes the condition can arise because a child is frightened of using the loo so has held back from going, thus causing the blockage in the first place. The technical name for this is 'retention with overflow'. The fear can be a result of past pain, because of a small tear, perhaps, when the child is straining, or it can be because the child has experienced a trauma while using the toilet. An adult shouting at him or her could have caused fear, or perhaps nearly falling in the loo itself. Even a fear of imagined monsters down the toilet can cause long standing problems.

Children who have some control but soil in the wrong place, may have first done this to protect themselves. For example, a toddler who is called a 'dirty little toad' when he first soils is likely to hide behind the settee next time he feels the urge to go. A child who has been brought up in an atmosphere where hygiene is not important may happily stoop to empty their bowels anywhere, such as the bathroom or bedroom, without thinking much about it. Young children who have been deprived of art materials may use faeces to 'draw' on the walls or to play with. However, older children who smear faeces on walls are more likely to do so because they are angry, upset or confused. Maybe they have been so badly abused or rejected that it is the only way they can draw attention to the world that they exist.

Not surprisingly the effects on the child of having a soiling problem can be quite upsetting. The child suffers embarrassment and loss of self-esteem. They may lose friendship groups and may be teased or bullied. The physical bloating that some children may feel can lead to irritability and reduced appetite. Some children hide the evidence of an accident, out of embarrassment or fear. This can be a difficult habit to break, even in a loving foster home.

Helping the child to improve

Children who are not yet five can usually be toilet trained as if this were the first training they have received. However, this will depend on the child's past experience. For older children, most families find it really helpful to externalise the problem. That is, to tackle the problem by separating it from the child. To do this, they imagine the problem as a character called 'Sneaky Poo' and help the child to find ways of beating 'Sneaky Poo' (White, 1984). This approach can include the strategies outlined below, within the framework of the child and carer working together.

If you are the parent or carer, explain this concept to your child and together draw up a plan. Some children like to draw their idea of 'Sneaky Poo' and illustrate the plan. The following guidelines and strategies can help in putting the plan together:

1. If your child does not have a regular bowel habit, then arrange a physical check with the doctor before starting to formulate a plan. Your child is more likely to succeed if any old constipation is cleared out before starting.

2. Make sure your child has a diet rich in fibre and drinks plenty of fluids. Cut down on food and drinks that tend to slow down the bowels or fill the child up, such as milk and sweets.

3. Do not speak about the soiling to anyone else while the child is present, but otherwise treat it like any other problem.

4. Do not get angry and ensure that no-one calls your child dirty or rude. A child who is upset is likely to avoid the problem rather than work on it.

5. Sit and talk to the child to put the problem in context. Emphasise all the things they are good at and all the things they are getting better at. Explain that with time and lots of practice they will be able to beat 'Sneaky Poo'.

6. If your child is having accidents in school, talk to the teachers and see if you can have permission for him or her to leave class whenever they need to go, without having to ask. Some children cannot face using school toilets when other children are around or feel an urgency to go during the training period. Teachers can give them a card to place on the desk as they leave to use the toilets.

7. Take very small steps. For example, the first step might be for the child to stop hiding dirty pants, so a reward system can be set up to give a small reward for each day the dirty pants have gone into a bucket by the loo (or in the bedroom). Don't start rewarding for clean pants or the child might start retaining faeces.

8. Help your child establish a good routine e.g. sitting on the toilet for a few minutes, half an hour after breakfast and again after tea. Give rewards just for sitting on the toilet and trying to go - if the child is successful give two rewards. The reward can be a star on a chart, pennies in a jar or whatever suits your child. Once rewards are given, never take them away. If you are using stars give a tangible reward for a certain number of stars. (See the article in Caring, Spring 2003 which includes more information on reward systems, or refer to Ollier & Hobday, 1999).

9. In addition to giving rewards, be very, very positive and celebrate small successes.

10. When sitting on the toilet, some children find blowing toys useful. Blowing bubbles, toy trumpets or party blowers uses the tummy muscles, so it is harder for children who retain faeces to hang on to them.

11. Make going to the toilet fun and not a punishment. The toys mentioned above will help but there may be other things that a child can play with only there, or perhaps you can lend moral support and read a story all at the same time.

12. When there is an accident, do not make a fuss. Reassure the child that together you will help them beat 'Sneaky Poo'. Try to keep your child motivated.

Following the above should help your child to begin to use the toilet. However, it can be a long process. If the problem has been around for many years, it may take many months to resolve. It is important that you find your own support during this time. If there are two of you caring for your child, then work together and have regular discussions about how things are going. If you are in a caring Christian community then look around to find someone who is practical and level headed, and ask if they can give you regular support while you are working on this problem. Or, for looked after children, there may be a social worker who can support you.

Case Study

Jerry, aged 10, had always soiled. His habit of hiding dirty clothes and sometimes smearing faeces on the walls or dropping them on the carpet had caused major problems in his last three foster placements. He was then placed with a very warm and positive carer. When she became upset by the smell and concerned at her failure to help Jerry, she asked her doctor to refer him to the hospital. He first saw a paediatrician who checked that all was physically correct and sorted out some medication to help clear out his very blocked bowels. Jerry then saw a clinical psychologist. The approach the psychologist took included helping Jerry to feel safe and secure in other ways, then externalising the problem. Jerry and his foster carer became enthusiastic about beating 'Sneaky Poo'. Jerry made some good progress with some routine training but then his carer became ill and he regressed. It was easy to see that his problem was partly connected to feeling safe and that his motivation alone was not enough for him to go it alone without his carer's help. As she got better, she was able to help him pick up on the fight to beat 'Sneaky Poo'. Jerry still needed some medicine sometimes to sort out his constipation but beginning to have successes on the toilet helped him to be more confident. He decided to completely beat 'Sneaky Poo' before his 11th birthday and managed to do so. The problem of dirty underclothes disappeared once he was regularly using the toilet. Jerry's appetite picked up and he enjoyed his healthy diet. He became more confident both at home and school.
As you see from the example, children can drop back in their progress but then pick up again. If there is a setback, try not to be discouraged but remember your child is learning something new and is bound to get it wrong sometimes. Help your child to become re-motivated again.

If you are unable to make progress, then you may need to ask for a referral to a paediatrician and a clinical psychologist. This is best done through your family doctor or through the community paediatrician. Do not feel that you have failed if you have to do this. I always think that the best carers are the ones who seek appropriate help for their child.

References:

Ollier, K. & Hobday, A. (1999) Creative Therapy 2: Working with Parents, BPS Blackwell, Oxford.

White, M. (1984) Pseudoencopresis: From Avalanche to Victory, from Vicious to

Virtuous Circles. Journal of Family Systems Medicine, 2(2).

For reasons of confidentiality, the example I have used is based on my clinical experience and is not related to any one client. It is the kind of referral I often receive.

Click here to return to the Articles menu.