medical condition except thr ough a mechanism involving constipation (Criterion D).
When the passage of feces is involuntary rath er than intentional, it is often related to
constipation, impaction, and retention with subsequent overflow. The constipation may
develop for psychological reasons (e.g., anxiet y about defecating in a particular place, a
more general pattern of anxious or oppositional behavior), leading to avoidance of defeca-
tion. Physiological predispositi ons to constipation include ineffectual straining or paradox-
ical defecation dynamics, with contraction rath er than relaxation of the external sphincter
or pelvic floor during straining for defecati on. Dehydration associated with a febrile ill-
ness, hypothyroidism, or a medication side ef fect can also induce constipation. Once con-
stipation has developed, it may be complicated by an anal fissure, painful defecation, and
further fecal retention. The con sistency of the stool may vary. In some individuals the stool
may be of normal or near-normal consistency. In other individuals—such as those with
overflow incontinence secondary to  fecal retention—it may be liquid.
Associated Features Supporting Diagnosis
The child with encopresis often feels ashame d and may wish to avoid situations (e.g.,
camp, school) that might lead to embarrassment. The amount of impairment is a function
of the effect on the child's self-esteem, the degree of social ostracism by peers, and the an-
ger, punishment, and rejection on the part of  caregivers. Smearing feces may be deliberate
or accidental, resulting from the child’s attempt to clean or hide feces that were passed in-
voluntarily. When the incontinence is clearly deliberate, features of  oppositional defiant