Dr Judith Guedalia

When The Mouth Can't Speak... (Part I)

"I can't believe I finally reached you," said the harried voice at the other end of the phone. "I have been trying to call you for months."  

"Trying to call me for months? I usually have a pretty good 'call-back-return' time," I answered.

"Oh no," she said, "I didn't leave any messages, nor did I reach anyone in your office. I meant I have been meaning to call you for months." So at least one area of contention was explained!


She went on to describe that her son was having "social problems" at home and at school. He was also "in trouble" with most of his teachers. 

The first intervention with a patient occurs with the first phone call or, sometimes though rarely, with a letter requesting an appointment. Much information can be culled from a phone conversation - information that can be expanded upon during the first formal "Intake" meeting.

So I asked her to describe "social problems," which can be anything on the neuropsychological "radar screen" - from Frontal Lobe injury, to stroke, to Right Hemispheric Disorder, to Non-Verbal Learning Disabilities, to Autistic Spectrum, or anywhere else on the brain-behavior continuum. She answered that he had "issues" with personal cleanliness. I waited. He is encopretic. She began to explain the word. I told her I was familiar with the diagnosis.

According to the DSM-IV-TR® (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; Text Revision, American Psychiatric Publishing, Inc. / Jaypee; 4th Edition-June 2000), 531 Elimination Disorders - and specifically Encopresis - appear in the following forms: With Constipation and Overflow Incontinence, and Without Constipation and Overflow Incontinence. It is not to be confused with Enuresis (also an Elimination Disorder). Interestingly Encopresis does not generally/normally occur at night.


Encopresis is diagnosed when:

  • Accidentally or purposely, the patient repeatedly passes feces into inappropriate places, i.e. clothing, the floor.
  • For at least three months, this has happened at least once per month.
  • The patient is at least four years old (or the developmental equivalent).
  • This behavior is not caused solely by substance use (such as laxatives) or by a general medical condition, but through some mechanism that involves constipation. (Mechanisms that involve constipation could include hypothyroidism, side effects of medication, and a febrile illness that causes dehydration.)

Enuresis is diagnosed when:

  • Accidentally or purposely, the patient repeatedly urinates into clothing or the bed. The clinical importance of this behavior is shown by either of the following:
    a. It occurs at least twice a week for at least three consecutive months, or b. It causes clinically important distress or impairs work (scholastic), social or personal functioning
  • The patient is at least five years old (or the developmental equivalent).

This behavior is not directly caused by a general medical condition (such as diabetes, seizures, or spina bifida) or by the use of a substance (such as a diuretic). It is described as Nocturnal Only; Diurnal Only; and Nocturnal and Diurnal.

            (For more information, visit www.networktherapy.com.)

            Over the years I have seen many different children with Encopresis, and many more with Enuresis. Examples: Those who left a "gift" at home for someone to find; those that were constipated for a period of time and then "smeared"; and those that "leaked" during the day at home or at school. What amazes me still is how long it takes the parents, and truly the child, to get help.

One case in particular comes to mind. The father came first by himself. "You don't have to see my wife to understand the problem," he said. The child would "retain" for weeks, and have stomach cramps. They would give him stool softeners, and he would finally be convinced to go to the toilet. Once there, he pressured his parents to "empty" the room, i.e. take out the towels, soap, toothbrushes and anything else around. Then he would close the door to the toilet. Upon reentering they would find feces smeared all over the toilet bowl, bathtub and other surfaces.

"How long has this been going on?" I asked, assuming the answer to be days or weeks. "Six or seven months," said the father. Astounding, I thought, and how sad that this poor child and his parents have had to suffer for such a long time.

Generally speaking, in my experience with psychological intervention, the "symptom" should be gone within a month or so. After the first month, accidents may happen over the next three months. Once the "cause/underlying issue" is resolved, the behavior/symptom does not persist.

Back to the case at hand: 

At the appointed time, I invited Sara and Moses Banai and their 12-year-old son Zvi (not their real names) into my office. They came in and all three moved their chairs so that they each sat at some distance from one another. Uhmm, I mused to myself, three islands near each other; is that an archipelago? But it might be a sign of communication difficulties between the family members.

I asked Zvi why he came. He put his hands to his ears to block out sounds and said in a quiet voice, "Ask them." I had a lot of information already, so I asked Zvi if he would mind sitting in the waiting room while I spoke with his parents. A huge smile appeared on his face, he held his hand out wordlessly toward his father who placed a seriously "gagetized" cell phone in his son's outstretched hand, and he was out of the room.

His parents then began telling their story, which ran the gamut from embarrassment, shame and blame, to anger, tears and frustration - and other emotions in between. They began speaking at the same time and either echoed or disapproved of the others' remarks.

"Okay, it's my turn to talk now," I said. "I understand this part of the family story. Can you each tell me a bit about your families of origin?" I asked Moses to tell me about his wife's. That was a surprise. He began slowly, measuring his words so as not to wound with his usually verbal, explosive manner of speaking. Sara voicelessly looked at her husband with appreciative eyes, as if to thank him for not saying everything there was to say and for saying what he did with kindness.

I turned to Sara and said, "Your turn to tell me about Moses's side." As she spoke, he sat wordlessly. She spoke softly and no longer in the shrill tones I had heard when she was describing what went on at home. She was especially supportive of her husband when she described how hard his childhood was, and how hard it must have been (and still is today) for him to live in close proximity to his intransigent and overly strict parents.

Then I asked them to call Zvi on the cell phone, and ask him to come in.

I thanked him for letting me have this time with his parents and for being so patient. He seemingly ignored me and brashly told his father that he wants the same cell phone. "It's not fair that you have such a good one and I have a rotten piece of 'junk' " (expression modified).

His parents looked at each other and at me, shocked and embarrassed. I smiled and thought, now we're cooking with gas. Instead I said, "Almost everything is negotiable. But you just have to learn how to ask, and especially how to speak with respect to the people from whom you want a favor."

"What did you talk about for such a long time?" he asked. I answered that we talked about his parents growing up, his grandparents, and things that are going on at home that are difficult for them all.

"Tell him to speak to me with respect first; tell him not to hit me; tell him not to scream; tell her not to cry and tell on me." Then he started to cry.

I said that our time is up, but one very important thing came out of this meeting. I said, "Zvi, whatever you do until our next appointment in three days, do not stop 'leaking' - please don't stop."

I got up from my chair. An hour and a half had gone by, and my next patient would be arriving any moment. Three people rose from their chairs in utter surprise. Numbly confirming the time and date three days hence, they left the room.

                                                 (To be continued)


Originally published in the Jewish Press on  August 6, 2008.


Tags: Constipation | Elimination Disorders | Encopretic | Enuresis | Jewish Press | Overflow Incontinence