The New Clean Kid Manual-III
Table of Contents (131 pages)

Preface: Can You Prevent Failure? Is There Success After Failure?

Chapter 1 An Overview

Our Manuals
Two Forms of Encopresis
The Physical Medicine View
The Behavioral View
“Behavioral Medicine” vs. the “Twilight Zone”
Policies and Change
Win-Win Unconditional Money Back Guarantee
Optional Consultation Services: Pay-per-Call; Unlimited Consults
Inform Your Physician?
Cautions for Treatment

Chapter 2 Bowel Accident Basics: Causes and Effects

Some Effects First! Zero Tolerance, Blame, & Social Rejection
Effects Out of All Proportion to the Causes
The Incidence of Encopresis and Toilet Training Delays
The Onset of Encopresis
The Role of the Brain in Blocking or Promoting Bowel Control
Genetic Factors
Hiding is a Contributing Factor
Add Going to School, Divorce, Vacations, and Strange Places
The Effects of Physical, Mental, and Emotional Activity
Special Causes and Insights for the School Age Child

Chapter 3 The Clean Kid Approach Is Not For Everyone

Getting Unstuck!
Moving On!
A Major Hurdle
All Together!

Chapter 4 Going Beyond the Mechanics of the Traditional Pediatric Approach

The Long Food Tube
Clearing the Tube
The Problem with Keeping the Tube Too Clear
An Overemphasis on the Role of Fiber
Sitting “Forever” Demands Can Cause More Holding
Getting Smart!
Willpower is Not Enough
The Soiling Solutions Solution

Chapter 5 Breaking Out Your Clean Inner Child: Making Love Loveable

The Coach Approach
The “Clean-Out”
Be Prepared
Required Materials for Treatment
Timing Between Sits
Timing Sits
Weaning Off of Laxatives
Introducing a Stool Softener
The First Two Sits Without Any Artificial Aid
The “Farting” Trick Loved by Boys and Some Girls
How to Estimate Amount of Stool
Glycerin
The Suppository and Enema as “Primers”
Slowing Down Speeds Up GI Activity
I Went at School, Mom! Hmmm, Really?
The Enema
Enema Failure
Diary Recording
Trends in Responses to Treatment
Relapses
Some Reasons for Relapses

Chapter 6 Troubleshooting Likely Problems

The Right Mousetrap
Telehealth and Internet Based Learning Works
Issues About Inserting Suppositories and Enemas
Preparation for Insertion or Exit Strategy No. 1
Insertion Strategy No. 2—Positive Practice
Insertion Strategy No. 3, Especially For Older Children
Insertion Strategy No. 4, If You Can Do It!
A Suppository Alternative to the Enema
A Farmer’s Pithy but Wise Saying
Personality and Temperament Factors in Dealing With Your Child
The Verbal, Insightful Child—You Should Be So Lucky!
The Reluctant Child
The Difficult Child
The Impossible Child
“Low Poop Producers” and Changing the Schedule
Responding to Children Stuck on the Suppositories or Enemas
The “Dependency” Issue
Altogether Now!
Give Up or Try Again Later?

Chapter 7 The Long Haul

Record Keeping and Treatment Reminders
An Early Sign of Progress
Tire Tracks: An Early Sign of Regression
When Do You Lower Your Guard?
Repeated Regressions and Your Alternatives

Chapter 8 What About Accidents: Can They Be Ignored?

The Clean or Good Smell Test
Optional Only

Chapter 9 Staying Clean

Relapse Prevention
Fine Tuning Your Antennae
Home Factors
Morale
Overlearning
Generalization of Learning
Training in Responsibility
Learning With Awareness

Chapter 10 Concluding Comments

Heroism?

INDEX

Appendices (These are all available on my website, except for No. 6 and No. 7. DrC.)

No. 1: Chapter on Enuresis and Encopresis by Dr. Collins

No. 2: Professional Conference Summaries (This links to just one conference, others are linked on the Clean Kid (Encopresis) Manual page toward the bottom)

No. 3: Recent Scientific Abstracts

No. 4: Megacolon in Cats and Kids

No. 5: Food, Diets, and Laxatives

No. 6: Optional Questionnaires for Mailing or Faxing

No. 7: The Soiling Success Diary 

PREFACE

Can You Prevent Failure? Is There Success After Failure?

Yes and Yes! I have become an expert in treating failures of bladder and bowel control. My program succeeds even after a variety of medical interventions have failed. Failure is not necessarily a bad thing if you learn from it and if you look at both the prevention and treatment sides of failure. Over the course of the past 35 years I have studied the issues of bladder and bowel continence from the unique position of a psychologist working with what is widely regarded as a medical problem (See reference list for publications below).

Bladder and bowel functions are clearly physical processes at work. But learning when and how to hold and when and how to release our body wastes also involves developmental and brain control mechanisms. Many physicians and psychologists who deal with enuresis and encopresis in academic settings and in university medical centers show some understanding of these ideas. Also, a lay movement has emerged in this country that offers important insights into this learning, providing a surprising vindication of my own views about conditioning for achieving continence. But only my contributions have put together the whole picture.

The 17th century French philosopher, René Descartes, divided the world into two exclusive realms, the mental (non-material) and the physical (real or material). Too many physicians and lay people have stuck with this “Cartesian Fallacy” even now in the twenty-first century. Western thinking has a bias favoring exclusively physical explanations that makes treatment of encopresis difficult. Many parents and physicians assume that “mental” factors are, in a sense, not real because of this philosophical legacy. How do you manipulate and correct something without substance? Our mental-behavioral life is in fact physical and real, with brain-neurological-muscle mediated consciousness and automatic overlearned reflex arcs (A.R. Damasio, 1994, A.R. Damasio, 1999, S. Finger 2000). Also, mental activity can now be observed in brain scans. However, this manual can only make passing reference to this profound issue and get on with offering insights about causes and treatment that parents and health providers can use on a step-by-step basis.

Offering a manual via the Internet for achieving bladder and bowel control has allowed me to extend my professional life into “retirement.” Indeed, the power of the Internet and telehealth has been very freeing for me. It may provide a vehicle for my enuresis and encopresis protocols to powerfully influence parents and professionals. Frankly, I think I have a better “mousetrap” that will eventually become a standard for treating both. The bedwetting alarm, which I helped to validate (Collins, 1973), is already well established in many first world countries. Fortunately, there is an American tradition of pragmatism, which may eventually result in better acceptance of behavioral solutions. We like something if it truly works, if it is practical, and if we can do it ourselves. We are a nation of “do-it-yourselfers.”

There is a movement coming out of third world countries that is now being “discovered” in the USA and the Commonwealth countries. It may prevent failures in toilet training by addressing the subject much earlier. It is called “Infant Potty Training”. Laurie Boucke introduced this approach into our culture in 1991 with her first book, Trickle Treat (1991, out of print). Her later book, published most recently in 2004, bears the title, Infant Potty Training. Ingrid Bauer (2001) wrote Diaper Free: The Gentle Wisdom of Natural Infant Hygiene along similar lines, expressly challenging diaper manufacturers. I have trademarked “Dump Diapers” and so share similar sentiments. These authors have been working hard to promote the earlier and wider acceptance of natural toilet training. Also, there is a very active group of parents supporting and advising one another on the Elimination Communication (EC) discussion list at yahoogroups.com. These parents also tend to practice “natural” childbirth, breast-feeding, home schooling, and the family bed. Their accounts are very convincing that sphincter control is achievable at much earlier ages than has been commonly assumed in the U.S.

These parents actually consider 6 months and older children to be “late-starters”. Basically, the parents “tune in” from infancy to any signs that their child is getting ready to pee or poop. They find a container, the sink, the tub, or the toilet and hold the child over it while saying “psss”, “unh-unh”, “potty” or some such verbal cue to associate it with the act of peeing or pooping. Eventually, they can help their child to associate voiding urges with their cueing effort using a container, and not leave it to chance voiding into diapers as a convenience factor. The parents are very sensitive and tune into their children’s needs, and enjoy early and rich interactions with their children. I am hopeful that this movement may help to prevent the failure of toilet training for some children. However, infant potty training is time intensive and many of today’s working parents may not find it to be a viable option.

There are many practical reasons for parents to rely on disposable diapers and laundering services, which are so easily available for so long. Some pediatricians actually encourage delays in toilet training, believing that it is inherently a coercive process and that children “will grow out of it” when they are “ready.” They counsel patience and bigger diapers, which the diaper manufacturers are only too happy to provide. However, in effect, by default, if this goes on for too long children are trained to go into their diapers! If this persists it becomes a habit, which will be hard to overcome when serious attempts are made to transition the child to the toilet. Attempts at toilet training are the number one factor associated with children holding stool and resisting the toilet. This causes stool to back up, harden, and enlarge the colon. Note that here the original and most relevant cause for encopresis is the “gate control” mechanism at the end of the GI tract. The child’s anal sphincter is holding or locking up the stool. The enlargement of the colon is a delayed consequence, which complicates treatment. It helps to perpetuate the problem. However, it is not central to a cure. Train the voiding reflex and the colon’s recovery will follow! This is not understood by many of today’s experts.

On the professional side, the pediatric and GI physicians remain very stuck on the mechanics of clean-outs and using oral laxative medications. They use a simple-minded Dr. Drano or Mr. Plumber equivalent for keeping poop moving when failures of normal training occur. Admittedly, there is a proper concern for the possible but extremely rare rupture of the colon resulting in a massive infection and death. Another idea here is that promoting a constant flow will reduce the enlarged colon over time and that this will somehow allow everything to work properly. If a psychologist is called in, he/she may attempt to mediate this process using systematic reinforcement or exploring deeper emotional issues. The sphincter mechanism, which is the original and most relevant cause for encopresis, is often overlooked from this physical medicine perspective. A very few physicians appear to acknowledge this possibility when they finally refer the child on for biofeedback, which can address the gate control mechanism.

In practice, many children are going to learn good bowel control regardless of environmental, developmental and possible genetic factors. It is when the child fails to train that parents go to the child’s physician to address the issue. Physicians, parents, and our culture have tremendous faith and a large investment in oral medications. Thoughts of surgery, putting in medication from the opposite or bottom end, and biofeedback are resisted.

Reports in two prestigious medical journals (D. Levine & H. Bakow, 1976 and D. Levine, 1982) seriously biased the medical community against the use of suppositories and enemas. The lead author for both reports used such terms as “anal assault” and “anal stamp” to describe the use of suppositories or enemas in treating encopresis. The oral approach came to be referred to as the “gentle” approach. I was horrified to see these judgmental statements being inserted into medical journal articles. This bias is still active within modern medical circles. As one result, Gold, D.M., Levine, J., Weinstein, T.A., Kessler, B.H. & Pettei, M.J. (1999) found that a good three-fourths of children had not had digital (finger) examinations to reveal the contractile strength of the anal sphincter, competency in pushing, and the consistency of the stool prior to their presentation to the Division of Pediatric Gastroenterology at the Schneider Children's Hospital in New Hyde Park, NY. The likelihood of actual sphincter damage or weakened sphincter contraction could be present and could recommend surgical repair. This is unlikely in children. It is more typical of women after childbirth or in the elderly. If there is impaction the physician may manually break up and extract the hardened stool. A legitimate and well-indicated medical examination procedure appears to have fallen into disfavor because of cultural fears and a medical bias in the literature (O.S. Palsson & R.W. Collins, 2003).

The oral approach does somehow work in 50 percent or so of cases. Parents and professionals alike may want to try the oral approach first if they are uncomfortable using suppositories and enemas. However, in my experience the Clean Kid protocol has proven more effective. The Clean Kid Manual III utilizes carefully timed free sitting opportunities, gentle glycerin suppositories, and enemas at the proper end of the GI tract only as they are necessary to promote reliable, timely daily voidings. Done properly, using our manual, the child gains control over his/her own natural gastrocolic reflex and ends encopresis promptly. In my view biofeedback is not necessary in the vast majority of instances. The child’s brain-body connections become self-sufficient, learning when to hold, when to go, and how to do both effectively. This restored “gate control” at the end of the colon takes away the emphasis on the enlarged colon as the central problem. Regular daily voidings reduce the pressure on the colon so that now the colon can recover even as the child learns and achieves bowel control. This is a much kinder and more morale boosting approach than months and months of failure.

References

Bauer, I. (2000). Diaper free! The gentle wisdom of natural infant hygiene. Saltspring Island, British Columbia, Canada: Natural Wisdom Press.

Boucke, L. (1991). Trickle treat (Out of Print). Lafayette, CO: White-Baucke Publishing.

Boucke, L. (2000, 2003 rev., & 2004 rev. ). Infant potty training: A Gentle and Primeval method adapted to modern living. Lafayette, CO: White-Boucke Publishing.

Collins, R. W. (1973). Importance of the bladder-cue buzzer contingency in the conditioning treatment for enuresis. Journal of Abnormal Psychology, 82(2), 299-308.

Collins, R. W. (1976). Applying the Mowrer conditioning device to nocturnal enuresis. Journal of Pediatric Psychology, 4, 27-30

Collins, R. W. (1980). Enuresis and Encopresis. In Woody, R. H., Encyclopedia of Clinical Assessment. San Francisco: Jossey-Bass.

Collins, R. W. (2004). Bottom line: Bowel health in children. Quality Care (National Association for Continence), 22(1), 6.

Damasio, A.R. (1994). Descartes” error: Emotion, reason, and the human brain. New York: G. P. Putnam’s Sons.

Damasio, A. (1999). The feeling of what happens: Body and emotion in the making of consciousness. New York: Harcourt, Inc.

Finger, S. (2000). Minds behind the brain: A history of the pioneers and their discoveries. New York: Oxford University Press.

Gold, D.M., Levine J., Weinstein, T.A., Kessler, B.H., & Pettei, M.J. (1999). Frequency of digital rectal examination in children with chronic constipation. Archives of Pediatric and Adolescent Medicine, 153(4), 377-379

Levine, D. (1982). Encopresis: Its potentiation, evaluation, and alleviations. Pediatric Clinics of North America, 29(2), 315-330)

Levine, D. & Bakow, H. (1976). Children with encopresis: A study of treatment outcome. Pediatrics. 58(6), 845-852)

Palsson, O. S. & Collins, R.W. (2003). Functional bowel and anorectal disorders. In Moss, D. M., McGrady, A., Davies, T. C., & Wickramasekera, I. (Eds.), Handbook of mind-body medicine for primary care (pp. 299-311). Thousand Oaks, CA: Sage Publications.