Psychological & Behavioural Factors Associated with Encopresis James Banham Ipswich Hospital

Psychological & Behavioural Factors
Associated with Encopresis
James Banham
Ipswich Hospital
Overview
• What is the Biopsychosocial Model
• Bob and a Biopsychosocial Model of Encopresis
– Predisposing Factors of Encopresis
– Triggering Events Associated with Encopresis
– Maintaining Factors of Encopresis
• Take Home Message
• Questions
Biopsychosocial Model
• The patient is viewed as being embedded within a series of
systems that reciprocally interact with one another that impacts
the patient’s ability to cope and recover
– Biological factors: anatomical, structural
& molecular substances of a medical condition
and its effects on biological functioning
– Psychological factors: effects of
psychological wellbeing, motivation
and personality on the experience
or reaction to a medical condition
– Social Factors: cultural, environmental
and familial influence of the expression
and experience of a medical condition
Bob & a Biopsychosocial Model of Encopresis
My Ideal Referral Question:
Please kindly review Bob who is a 10 y.o. Caucasian male with significant
history of unresolved problems with constipation & soiling. Never been
toilet trained. He continues to wear nappies and refuses medication.
Please assist with management.
Bowel function at intake:
Passed a large hard bowel
motion once every 1-2 weeks
and significant overflow
6-7 times a day
Biopsychosocial Predisposing Factors:
Individual Context
Individual Biological Factors
• Poor sensation to rectal filling
• Congenital mega-rectum
• Anorectal abnormalities
Individual Psychological Factors
• Temperament and Early attachment
• Intelligence & Developmental
• Attention difficulties
• Impaired social skills
• ASD
• Toilet Readiness
Biopsychosocial Predisposing Factors:
Family & Social Context
• Parental personality characteristics
• Coercive/ punitive behaviour management strategies & inadvertent
rewards
• Parental skill set re. avoidance/anxiety
• Chaotic family environments
• Previous experiences with health professionals & health beliefs
• Abuse
• Early life exposure to family problems
• Low Socio-economic status
• Limited social supports
• Previous negative experiences with health professionals
Triggering Event/s
• Individual Factors
•
•
•
•
•
Anal Fissures
Gastrointestinal illness
Chronic constipation
Low fibre diet
Low water intake
• Family & Social Factors
• Coercive/ punitive/ intrusive toilet training
• Acute life stressors
• Lack of privacy when toileting
Biopsychosocial Maintaining Factors of Encopresis:
Individual Biological Level Initial
Predisposing Factors
Withholding
Fear of painful
bowel motion
Bowel starts to
stretch
Brain starts to
ignore defecation
urge
Stomach pain/
Nausea
Painful bowel
motion
Biopsychosocial Maintaining Factors of Encopresis :
Individual Biological Level Escalation
Predisposing Factors
Fear of painful bowel
motion reinforced
Painful bowel
motion
Withholding
Stomach pain/
Nausea
Overflow of faecal
material into
underwear
Bowel
stretches
Brain ignores
defecation urge
Stool becomes
harder & painful to
pass
Rectum continues
to fill
Overstretched bowel & reduced
sensitivity to defecate
Biopsychosocial Maintaining Factors of Encopresis :
Individual Psychological & Behavioural Level
Predisposing Factors
Fear of painful bowel
motion reinforced
Painful bowel motion
Withholding
Overflow of faecal
material into
underwear
Potential
secondary gains
to soiling
Stomach
pain/
Nausea
Stool is harder &
painful to pass
Increased resistance to
engage in pro-bowel/
appropriate toileting
activities
Brain ignores
defecation
urge
Bowel
stretches
Child
embarrassment/
guilt about passing
bowel motion hides prior to BM
Rectum continues
or soiled
to fill
underwear
Overstretched bowel &
reduced sensitivity to
defecate
Significant emotional
disturbance may start to
develop
Learnt helplessness denies/ unaware of soiled
underwear & odour
Psychological Differences Between Children with and
without Chronic Encopresis
(Cox, Morris, Browitz & Sutphen, 2002)
• Comparisons between sibling &
non-sibling groups did not
significantly differ on an measure
• Encopretic children experienced:
– Greater number of anxiety and depression
symptoms
– Family environments with significantly
lower levels of expressiveness and
organisation
– Difficulties with attention
– More social problems
– Demonstrated more disruptive behaviours
– Lower levels of academic performance
– No differences in self-esteem
Biopsychosocial Maintaining Factors of Encopresis :
Family Level
Predisposing Factors
Painful bowel motion
Potential
secondary gains
to soiling
Increased
family stress
Overflow of
faecal material
into underwear
Fear of painful bowel
motion reinforced
Stomach
pain/
Nausea
Stool is harder
& painful to
pass
Increased resistance to
engage in pro-bowel/
appropriate toileting
activities
Increased
likelihood of family
social isolation
Withholding
Bowel
stretches
Brain ignores
defecation urge
Rectum
continues to fill
Overstretched bowel & reduced
sensitivity to defecate
Learnt
helplessness
Emotional
disturbance
Family develops –ve
view of child
Child embarrassment/
guilt reinforced
Parental attempts to
resolve soiling and
may neglect own
health needs
Parental
embarrassment/ anger
Biopsychosocial Maintaining Factors of Encopresis :
Social & School Level
Predisposing Factors
Fear of painful bowel
Painful bowel motion motion reinforced
Potential
secondary gains to
soiling
Increased
financial strain
Poor academic
performance
Overflow of
faecal material
into underwear
Increased resistance to
engage in pro-bowel/
appropriate toileting
activities
Stomac
h pain/
Nausea
Stool is
harder &
painful to
pass
Brain ignores
defecation
urge
Bullied/ teased for
soiling at school
Bowel
stretche
s
Rectum
continues to
fill
Overstretched bowel &
reduced sensitivity to defecate
Learnt
helplessness
Emotional
disturbance
Parental embarrassment/
anger re: child’s soiling
Family social isolation
Increased school
absenteeism/
refusal
Withholding
Family develops
–ve view of child
School requests
parents to change
child or sends child
home for soiling
Social
withdrawal
Parental attempts to
resolve soiling
Child attempts to
supress urge to
defecate more
Child guilt/
embarrassment
reinforced
Biopsychosocial Maintaining Factors of Encopresis :
Community Level
Predisposing Factors
Painful bowel
motion
Overflow of
faecal material
Potential into underwear
secondary gains to
soiling
Increased
financial strain
Poor academic
performance
Economic
Impact/ Health
Care Provision
Increased resistance to
engage in pro-bowel/
appropriate toileting
activities
Increased likelihood of
family social isolation
Increased
school
absenteeism/
refusal
Stomach
pain/
Nausea
Fear of painful
bowel motion
reinforced
Withholding
Bowel
stretches
Child embarrassment/
Brain
guilt reinforced
Rectum
ignores
continues
defecation
to fill
Overstretched bowel &
urge
Parental attempts
Stool is
reduced sensitivity to
to resolve soiling
harder &
defecate
Learnt
painful to
helplessnes
pass
Bullied/
s
Emotional
teased for
disturbance
soiling at
Parental
school
embarrassment/
Child attempts to
anger re: child’s soiling supress urge to
Family
defecate more
develops –ve
view of child
Community
stereotypes
School requests
parents to change
child or sends child
home for soiling
Low family help
seeking behaviour
Low Socioeconomic status
Questions for you
• What appropriate treatment goals might you
to pursue to assist Bob and his family recover
from encopresis?
• From what has been covered today, what
treatment interventions might be appropriate
in Bob’s treatment?
Take Home Message
Need to consider the systems in which medical
conditions like encopresis exists how they may
impact on a patient’s adherence to management
and treatment
Questions
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