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Memoirs of a "Poop Lady". (Casebook).

Article Excerpt
When I met 6-year-old Jorge and his parents in the Gastrointestinal Clinic of Children's Hospital, Jorge hadn't moved his bowels in 11 days. He was a small 6-year-old with luminous dark eyes and a seldom used smile. He had been stooling only intermittently for 2 years. Two recent attempts of administering laxatives by his overwrought mother and furious father had produced nothing but a runny brown liquid and a lot of hard feelings among family members. His father insisted that the doctors do something to help them, while his mother wept with frustration. Jorge, in contrast, held the demeanor of both obliviousness and polite disdain that one assumes when confronted by particularly rude social acquaintances. The room stank. I was beginning treatment with another encopretic.

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Encopresis is a difficulty some children have in which they soil their pants (after potty training age) apparently involuntarily, or withhold stool for days or weeks at a time. Functional encopresis refers to a disorder with the absence of organic difficulties. The child is just not getting to the toilet, or is behaving as if pooping were an elective. As a clinical social worker, I had seen families suffering from the effects of many different chronic illnesses, and the one that undid families more than I would have ever expected was encopresis. Over the years, my curiosity about this developed into a treatment specialty. This fact became clear when I walked into the exam room one day to meet a 5-year-old potty procrastinator who greeted me by demanding, "Are you the poop lady?" The question took me aback. Am I? Do I even want to be? The following experiences document the challenging road I've traveled in order to live up (or down?) to the honor.

My moniker as the "Poop Lady" was not hard won. No one wanted to work with these families, and not just because of the topic of discussion--one I find endlessly fascinating. Do you know how many words there are for poop? Do you know there are some families that can't bring themselves to call it anything? These cases just didn't get better. By the time they arrived at the hospital door, these children and families had failed many treatments, and often had suffered the ill effects of this problem for years.

The effects are notable. Hundreds of pairs of soiled underwear that, depending on the socioeconomic group of the philosophy of the family, were either thrown out or washed. Isolation. No sleepovers. Going to the store or anywhere, might be canceled or greatly delayed by an accident. Delayed, too, is the confidence that children normally experience when they successfully complete this basic right of passage. Going to school can be potentially humiliating, since these children long ago have disconnected from bodily signals to "go." Scads of unsolicited advice is received from friends and relatives. ("Give her to me for one week--she'll be toilet trained.") Ruined furniture, smelly bathrooms, long hysterical scenes as parents attempt to enforce the medication regimen, and competing toilet training techniques between well-meaning parents who can't face the fact that neither one of them has a clue what to do.

The failure is notable. These often were parents who had expended a great deal of energy and commitment in nurturing their children. The women held strong identities as good mothers, and they were failing at this most important milestone, and in a most public way. Sometimes other aspects of development and/or growth had not gone as expected, and this was the final straw. We were a GI clinic known in Northern California for its state of the art treatments, and we were also failing at alleviating these most basic symptoms. And always, there was anger, particularly the mothers at the kids, mothers at the doctors, and everyone else at the mother. Mother's anger was in stark contrast to her child's utter lack of affect. The child usually acted indifferent if not oblivious to his soiling or lack of BMs. Jorge, for instance, would insist he didn't need to go even as he squirmed back and forth in his seat, his sphincter muscles clamping his rectum shut.

Traditional psychological notions about "what's wrong" with a child who's encopretic may reflect its impact on theoreticians who had repeatedly observed this polarity of affect between parents and their children. It was believed that these mothers were having trouble facilitating the "separation process" with their youngster, and that the child's behavior represented a convoluted attempt to assert autonomy from this overinvolved, undifferentiated mother. It's easy to understand how one would come up with this assessment after spending even a short time with these families. A mother would often come in with handwritten pages detailing when, how and where the child did or did not poop. She was able to think of little else. Successful episodes of toileting were looked upon (by her) as either anomalies, or at best, times when her nagging or hyper-anticipation of his toileting needs had "worked" for the moment....