JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY

Volume 24, Number 3, 2014 Brief Report

ª Mary Ann Liebert, Inc.
Pp. 158–160
DOI: 10.1089/cap.2013.0023

Effect of OROS Methylphenidate on Encopresis in Children

with Attention-Deficit/Hyperactivity Disorder

Savasx Yılmaz, MD, Ayhan Bilgiç, MD, and Sabri Hergüner, MD

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Abstract
Objectives: Although encopresis shows a high rate of comorbidity in patients with attention-deficit/hyperactivity disorder
Journal of Child and Adolescent Psychopharmacology 2014.24:158-160.

(ADHD), the etiologic origin of this relationship and the effect of ADHD drugs on encopresis are unclear. In this chart review,
we explored the effect of OROS long-acting methylphenidate (MPH) treatment on encopresis in children with ADHD. We
also evaluated the relationship between the clinical variables of ADHD and encopresis.
Methods: The sample consisted of 21 children and adolescents (20 boys and 1 girl) with encopresis and coexisting ADHD
7–15 years of age. Their clinical characteristics and baseline (visit 1) and end of the second months’ (visit 2) Conners’ Parent
Rating Scale (CPRS) subscores were recorded. Retrospective clinician determinations were made using the Clinical Global
Impressions-Severity subscale (CGI-S) for encopresis severity and the Clinical Global Impressions-Improvement subscale
(CGI-I) for encopresis response.
Results: According to the CGI-I, 14 subjects (71.4 %) showed much or very much improvement in their encopresis at the
second visit. All of the CPRS scores showed a significant reduction during the second visit. No association was found between
the CGI-I score and the changes in any of the CPRS scores. Baseline oppositional defiant disorder (ODD) and conduct
disorder (CD) scores were correlated with the CGI-S score; however, no association was found between core ADHD symptom
severity and the CGI-S score. With regard to the encopresis outcome, the baseline CD score was negatively correlated with the
CGI-I score, and the baseline ODD score was prone to show a negative correlation with the CGI-I score.
Conclusions: These results suggest that coexisting behavioral problems may be a vulnerability factor based on the severity of
encopresis, and that MPH treatment may have a positive effect on encopresis in children and adolescents with ADHD.

Introduction anti-ADHD treatments’ effects on encopresis in children with

E ncopresis is a common disorder with a 1–3% prevalence in
the general pediatric population, and boys are more commonly
affected than girls (Loening-Baucke 2002; Culbert and Banez
2007). Despite the fact that the etiology of encopresis is unclear, it
has been associated with various psychiatric conditions, including
both internalizing and externalizing disorders (Cox et al. 2002;
Joinson et al. 2006; Akça et al. 2011). Psychiatric problems may
play a role in the development, maintenance, and treatment of the
disorder (Cox et al. 2002).
Attention-deficit/hyperactivity disorder (ADHD) is among the
most frequently reported coexisting psychiatric condition in chil-
dren with encopresis ( Johnston and Wright 1993). Although the
relationship between ADHD and encopresis is unclear, it has been
speculated that inattentive/impulsive children are less able to rec-
ognize and respond to internal cues to defecate, which causes the
encopretic behaviors (Cox et al. 2002). However, some authors
suspected that child–parent relationship conflicts and poor social
and school functioning related to ADHD may be responsible for the
development of the disorder (Bilgiç 2011). Several case reports
also support the relation between these two disorders, reporting
ADHD (Golubchik and Weizman 2009; Bilgiç 2011; Hergüner and
Hergüner 2012).
In this chart review, we explored the effect of OROS long-acting
methylphenidate (MPH) treatment on encopresis in children with
ADHD. We also evaluated the relationship between the clinical
variables of ADHD and encopresis.
Methods
Approval for the retrospective chart review was obtained from
the Institutional Review Board. The database of Meram Faculty of
Medicine, Child and Adolescent Psychiatry Out-Patient Clinic was
utilized to identify all children and adolescents with ADHD
(n = 932) who received services during the 1.5 year period from
June 1, 2011 to December 31, 2012.
The inclusion criteria were: Being from 6 to 18 years of age;
diagnosis of ADHD and coexisting encopresis, according to
American Psychiatric Association, Diagnostic and Statistical
Manual of Mental Disorders, 4th ed. (DSM-IV) criteria (American
Psychiatric Association 1994); and treatment with OROS long-
acting MPH. Diagnosis of the ADHD and encopresis were made by

Department of Child and Adolescent Psychiatry, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey.

158
 ADHD AND ENCOPRESIS 159

clinical interviews based on the DSM-IV criteria of these disorders Table 1. CGI-S and CGI-I Scores of the Patients
and recorded in the chart. The exclusion criteria included: Sig- at Visit 1 and Visit 2
nificant noncompliance with multiple missed medication doses
Visit 1 Visit 2
and/or visits in the first 2 months of the treatment; the presence of a
major physical or neurological illness (e.g., cardiac problems or CGI-S n (%) CGI-I n (%)
epilepsy); and major psychiatric disorders, such as pervasive de-
velopmental disorders, mental retardation, or psychotic disorders. Normal - Very much improved 4 (19)
Patients on polypharmacy or systemic treatments were also ex- Borderline ill - Much improved 11 (52.4)
cluded. All patients with encopresis received an initial physical Mildly ill 4 (19) Minimally improved 4 (19)
examination, appropriate laboratory tests, and consultations with Moderately ill 6 (28.6) No change 2 (9.5)
Markedly ill 5 (23.8) Minimally worse -
pediatric subspecialists in pediatric outpatient clinics to rule out
Severely ill 2 (9.5) Much worse -
physical disorders. In total, 21 ADHD patients met the study cri- Extremely ill 4 (19) Very much worse -
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teria, and their recorded clinical data were evaluated.

The data were extracted and independently checked by two sep- CGI-S, Clinical Global Impressions Severity; CGI-I, Clinical Global
arate investigators (SY and AB) for the following: Age, gender, Impressions Improvement.
diagnoses of ADHD and encopresis subtype, duration of the en-
copresis, OROS long acting MPH dosage, clinic progress of the
mean final OROS MPH dose at the 2nd month of treatment was
ADHD and encopresis, and baseline and 2nd months’ Conners’
Journal of Child and Adolescent Psychopharmacology 2014.24:158-160.

25.7 – 8.2 mg/day.

Parent Rating Scale (CPRS) scores. In our clinic, the CPRS was
All of the CPRS subscores showed significant reductions over
routinely completed by parents to evaluate the treatment outcome of
visits 1 through 2. According to CGI-I, 14 subjects (71.4 %) ex-
ADHD patients, especially during medical treatment dose adjust-
perienced much or very much improvement at visit 2 (Table 1).
ments. Because the MPH dose adjustment was completed in the
There were no significant differences between the primary and
many of the patients’ 2nd month of treatment, the baseline (visit 1)
secondary encopresis groups in terms of encopresis response. No
and 2nd months’ (visit 2) CPRS scores were used in this study. The
association was found between CGI-I score and the changes in the
CPRS is a four point Likert type 48 item scale, which includes
any of the CPRS subscores between visits 1 and 2.
subscales for attention deficit (AD), hyperactivity (HA), oppositional
We also examined the effect of baseline ADHD and coexisting
defiant disorder (ODD), and conduct disorder (CD) (Goyette et al.
disruptive behaviors symptoms on the encopresis course. The
1978; Dereboy et al. 2007). Retrospective clinician determinations
baseline ODD and CD severity were correlated with the CGI-S
were made using the Clinical Global Impressions-Severity subscale
score, whereas no association was found between core ADHD
(CGI-S) for encopresis severity and Clinical Global Impressions-
symptom severity and the CGI-S score (Table 2). With regard to
Improvement subscale (CGI-I) for encopresis response (Beneke and
encopresis outcome, the baseline CD score was negatively corre-
Rasmus 1992). The CGI scores were rated by the same investigator
lated with the CGI-I score and the baseline ODD score was prone to
(SH), who was blind to the course of the ADHD treatment, using the
show a negative correlation with the CGI-I score (Table 2).
extracted clinic progress notes about the encopresis. The CGI-S rates
severity from 1 (normal) to 7 (severely ill). The CGI-I assesses
Discussion
encopresis symptoms relative to a baseline with 1 being very much
improved, 2 much improved, 3 minimally improved, 4 no change, Given the reported relationship between encopresis and ADHD,
and 5–7 representing minimally, much, and very much worse. we retrospectively examined the effect of OROS MPH on en-
copresis in children and adolescents with ADHD. The study also
Statistical analysis sought to determine whether the clinical characteristics of ADHD
played a role in the encopresis course. The overall success rate for
The analysis of the data was performed using SPSS 17.0 sta-
encopresis (very much or much improvement) was 71.4% at the end
tistical software (Chicago, IL). The descriptive statistics of the
of the 2nd month of OROS MPH treatment. The results of this study
patients’ demographic characteristics and clinical features were
also revealed that coexisting conduct problems may be a vulnera-
calculated. The Wilcoxon rank sum test was used to analyze
bility factor for the severity of encopresis, and they seem to be
the differences in the CPRS subscale scores between visits 1 and 2.
associated with the success of the OROS MPH treatment for en-
The Spearman correlation coefficients were calculated to examine
copresis in children and adolescents with ADHD.
the relationship between CPRS and CGI scores. The significance
To date, the knowledge regarding the effect of ADHD drugs on
level was set at 0.05 (two tailed).
encopresis has relied solely on a few case reports (Golubchik and
Results
The mean age of the children and adolescents admitted to the Table 2. The Correlations Between Baseline
clinic was 8.67 years (SD: 1.98, range: 7–15 years), and the sample CPRS and CGI Scores
consisted of 20 (95.2%) boys and 1 (4.8%) girl. Sixteen subjects Mean – SD CGI-S rs (p) CGI-I rs (p)
(76.2%) had been diagnosed with ADHD (combined type), and five
(23.8%) had been diagnosed with ADHD (inattentive type). Of the Attention deficit 9.47 – 2.80 - 0.00 (0.998) - 0.17 (0.450)
participants, 12 (57.1%) met DSM-IV criteria for secondary en- Hyperactivity 8.47 – 2.99 0.33 (0.140) - 0.17 (0.454)
copresis and 9 (42.9%) for primary encopresis. Constipation was ODD 6.76 – 2.94 0.61 (0.004) - 0.51 (0.017)
reported in six (28.6%) patients. The average duration of the dis- CD 13.23 – 6.16 0.70 ( < 0.001) - 0.42 (0.061)
order for cases with secondary encopresis was 27 months (SD: 20, ODD, oppositional defiant disorder; CD, conduct disorder; CPRS,
range: 3–66). Enuresis (66.7%) and ODD (66.7%) were the other Conners Parent Rating Scale; CGI-S, Clinical Global Impressions
most common coexisting disorders, followed by CD (33.3%). The Severity; CGI-I, Clinical Global Impressions Improvement.
 160
Weizman 2009; Bilgiç 2011; Hergüner and Hergüner 2012). In
these reports, both MPH and atomoxetine have been effective on
encopresis in ADHD children. The authors suggest that the anti-
encopretic effects of these drugs may be related to the direct impact
they have on executive functioning, self-organizing skills, and
impulse control, which enable children to recognize and respond to
internal cues to defecate (Golubchik and Weizman 2009), or the
positive effects of ADHD drugs may be secondary to the resolution
of child–parent relationship conflicts and poor social and school
functioning (Bilgiç 2011). Given its expected course and the low
response rate to standard treatments in short-time periods, the
higher response rate we achieved supports the benefits of MPH
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treatment on encopresis in children and adolescents with ADHD.
However, no association was found between the improvement in
encopresis and the changes in the core symptoms of ADHD or
coexisting conduct problems between two visits. These results may
be related to our small sample size, which may preclude their
contributing to our understanding of the possible mechanism re-
Journal of Child and Adolescent Psychopharmacology 2014.24:158-160.
garding ADHD treatment and encopresis.
Previous studies consistently show a robust relationship between
behavioral problems and encopresis (Cox et al. 2002; Joinson et al.
2008). Cox et al. (2002) report that both teacher and parent ratings
show that children with encopresis had more delinquent behaviors
than those in the control groups. Another study found a relationship
between difficult temperament in early childhood and a subsequent
increase in the odds of children experiencing encopresis ( Joinson
2008). The results from the present study add to the existing litera-
ture and reveal the positive relation between the severity of en-
copresis and disruptive behavior disorders. This study has also
provided evidence that the children with higher baseline disruptive
behavior scores are prone to show better responses to MPH treatment
for encopresis. Although the underlying relationship between dis-
ruptive behaviors and encopresis is not clear, disruptive behaviors
likely affect the child’s compliance to his/her parents’ requests,
which prevents the behavioral treatment of encopresis (Kuhn et al.
1999; Hultén et al. 2005). A study conducted by Levine et al. (1980)
supported this idea and found that children with encopresis who did
not respond to treatment scored higher on antisocial-aggressive be-
haviors before treatment. Our findings might indicate the importance
of disruptive behavior treatment for encopresis management.
The retrospective nature of the present study is a significant
weakness. Other substantial limitations of this study are its small
sample size, male predominance, the short duration of the follow-
up, and, as in any naturalistic study, the open use of medication.
Conclusions
In summary, this study provides preliminary evidence regarding
the effect of MPH treatment on encopresis in children and ado-
lescents with coexisting ADHD, especially those who have had
greater disruptive behavior problems. The results also indicate that
there was an association between the severity of encopresis and
disruptive behavior disorders. Our study will be followed by ran-
domized controlled studies with larger samples, to better identify
the possible antiencopretic effect of MPH for ADHD patients.
Clinical Significance
The underlying relationship between ADHD and encopresis was
unclear. Whether the treatment of ADHD has an effect on encopresis
was unknown. The present study observed that the severity of dis-
ruptive behavioral disorders and encopresis show a strong correlation.
This study also reported the higher effect ratio of OROS long-acting
YILMAZ ET AL.
MPH on encopresis in children and adolescents with coexisting
ADHD, especially those who had more disruptive behavior problems.
Disclosures
No competing financial interests exist.
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Address correspondence to:
Savasx Yılmaz, MD
Department of Child and Adolescent Psychiatry
Necmettin Erbakan Üniversitesi
Meram Tıp Fakültesi
Cxocuk ve Ergen Psikiyatrisi AD
42090, Meram/Konya
Turkey
E-mail: drsavash@gmail.com