الفهرس 
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Abstract
Encopresis (or fecal incontinence) is a disorder which affects children worldwide. It is even more stigmatized than enuresis and urinary incontinence and is associated with high levels of distress for both children and parents. Also, the rate of comorbid emotional disorders is higher, affecting 30%-50% of all children with encopresis. Two major forms of encopresis can be differentiated: encopresis with and without constipation. The specific differentiation into these two subtypes is of utmost importance as they differ according to pathophysiology, clinical features and, especially, treatment (i.e., the former does not respond to laxatives, while in the latter they are essential in treatment). Functional constipation Must include two or more of the following in a child with a developmental age of at least four years with insufficient criteria for diagnosis of irritable bowel syndrome: • Two or fewer defecations in the toilet per week. • At least one episode of fecal incontinence per week. • History of retentive posturing or excessive volitional stool retention. • History of painful and hard bowel movements. • Presence of a large fecal mass in the rectum. • History of large diameter stools that may obstruct the toilet. Criteria must be fulfilled at least once per week for at least two months. • This study was an attempt to assess patients with functional fecal incontinence and assessment of the effectiveness of behavioral training program for them. It was carried out at the Neuropsychiatry Department, Tanta University and Centre of Psychiatry, Neurology and Neurosurgery- Tanta University hospitals and pediatric surgery outpatient clinic of Tanta University Hospitals during the period from November 2018 to November 2019. This study was a comparative cohort study was performed on two groups: group (A) which includes 30 patients diagnosed with functional encopresis (is defined as both voluntary and involuntary passage of feces in inappropriate places in a child aged four years or older, after organic causes have been ruled out), receiving a behavioral training program and medication for 6 months. group (B) which includes 30 patients diagnosed with functional encopresis receiving medical treatment only for 6 months. Patients were excluded from this study if they had mental retardation or encopresis due to general medical condition. After obtaining a written consent, patients were subjected to the following: I- Clinical evaluation: 1- History Taking: • First passage of meconium. • Early bowel habits. • Duration of constipation and encopresis. • Possible relating initiating factors, previous treatment, duration & compliance. • 2- Examination of the patient: • Abdominal examination • Examination of the spine to exclude spina bifida. • Per rectal (P R) Examination. • Neurological examination 3- Investigations to exclude organic causes of encopresis: 1. Contrast enema 2- Plain X Ray. 3- Other investigations as required in selected cases like: • Ano-rectal manometry. • Colonic, transit study. • Anal endo sonography will be done. II- Psychiatric assessment: • Socio – demographic evaluation: Age, Sex, Educational level of the parents was classified to: illiterate or primary school education ,secondary education and university education or higher, Residence. • A selected battery of psychometric tests& scales including Fahmy and El Sherbini scale, B- Stanford-Binet Intelligence quotient (I.Q) fourth edition, WHO quality of life scale (WHOQOL-BREF), Kiddie schedule for affective disorders and schizophrenia for school-age children (6-18 Years) -present and lifetime (K-SADS-PL), The Children’s Depression inventory • (CDI), Revised behavior problem checklist and Parenting Behaviors Scale. Medical treatment: Disimpaction using either enema or laxatives& surgical evacuation in resistant cases. Maintenance therapy: on laxatives to make the child passes at least one motion /day for the first three months and then the treatment withdrawn or modified according to the patient response. Behavioral training program for treatment of encopresis, in the first stage, assessment of the patient psychologically then applying the medical treatment and behavioral training program for at least six months to 12 months. Patient’s management program will be reassessed psychologically again at the end of the program to assess its effectiveness. Designing management program : this included the review of available programs and selection of items suitable to Egyptian culture. This study revealed that: The differences between the studied groups as regards the age, sex, I.Q and educational levels of the parents did not reach statistical significance (p >0.001). the educational level of the father was classified to Illiterate or 1ry school that represented by 53.3% in group A& 46.7% in group B, Secondary school that represented by 26.7% in group A& 36.7% in group Band University education that represented by 20% in group A& 16.7% in group B. the educational level of the mother was classified to Illiterate or 1ry school that represented by 46.7% in group A& 50% in group B, Secondary school that represented by 30% in group A& 33.3% in group B and University education that represented by 23.3% in group A& 16.7% in group B. • It was revealed that the majority of the group A and the group B were middle socioeconomic status, followed by high socioeconomic status, then low socioeconomic status and the least was very low socioeconomic status. The extended family represented (66.7%) of the group A and (73.3%) of the group B while nuclear family represented (33.3%) of the group A and (26.7%) of the group B with no clinical significant difference between the two groups p value (0.573). We found that the rural residence represented 63.3% of group A and 53.3% of group B, while the urban residence represented 36.7% of group A and 46.7% of group B, with no clinically significant difference between the two groups p value (0.432). Normal parenting style represented 23.3% of group A and 16.7% of group B, while abnormal parenting style represented 76.7% of group A and 83.3% of group B with no clinically significant difference between the two groups (p value=0.519). There were no clinically significant differences between the studied groups regarding behavior problem outcome at the baseline according to Revised Behavior Problem Checklist outcome. The best results had lower scores; this indicates that the both groups had severe behavioral problems as they had high scores. There were clinically significant differences between the studied groups regarding behavior problem outcome at the end of treatment according to Revised Behavior Problem Checklist outcome. P values were (0.001). The patients of group (A) had lower scores than group (B) that indicate they had the best results. According to The Children’s Depression inventory The depression outcome at baseline in group A was (16.7%) and (13.3%) in group B, while the depression outcome at the end of treatment in group A was (6.7%) and • (10%) in group B. There were no clinically significant differences between the two studied groups regarding depression outcome at the base line and at the end of treatment. There were no clinically significant differences between the studied groups regarding quality of life outcome at the base line according to WHO quality of life scale domains (Physical, Psychological, Social relation, Environment). The best results had higher scores. At the end of treatment there were clinically significant differences between the studied groups regarding quality of life p value 0.001. group (A) patients had higher scores than group (B) that indicate group (A) had the best results. There was comorbidity with other psychiatric disorders; the most comorbid disorder in group (A) is ADHD which represented 53.3% followed by enuresis 50%, anxiety 26.7%, ODD 26.7%, depression 16.7%, Bulimia& Conduct disorder 6.7%, OCD and Post traumatic stress disorder 3.3%. While the most comorbid disorder in group (B) is enuresis 43% followed by ADHD 40%, ODD 33.3%, anxiety disorder 20%, depression& conduct 13.3%, Anorexia nervosa& Bulimia 3.3%. There were no clinically significant differences between the two groups. At the end of treatment the scores of problem behavior outcome decreased in both types of families but more in the nuclear family with clinically significant difference between the both groups. Also the scores of revised behavior checklist were decreased at the end of treatment that indicates improvement regarding behavior outcomes in relation to the educational level of the fathers of patients of group (A). The best results were found in the high education (university) and the same results were for the mothers. • We found that at the end of treatment the scores of revised behavior checklist were decreased that indicate improvement regarding behavior outcomes in relation to the social classes of patients of group (A). The best results were found in high social classes. There was negative correlation between the total behavior score and educational levels of the father of the patients of group (A) with statistically significant difference p value = 0.001 i.e. the higher the educational levels, the lower the total behavior scores (the best results). There was negative correlation between the total behavior score and social class of the patients of group (A) with statistically significant difference p value = 0.001 i.e. the higher the social class, the lower the total behavior scores (the best results).