Reference no: EM133245233

Question - Mary, age 4, is the daughter of two active duty officers in the US Army, neither of whom have a personal history of either mental illness or substance abuse. Her mother brought the patient into the child psychiatry clinic with the complaint that her daughter had recently started to withhold her bowel movements. This behavior was also coupled with increasingly defiant behavior at home and frequent temper tantrums. When asked about recent stressors, the patient's mother revealed that her husband was geographically separated from them. He had lived with the family until Mary was 3½ years old. He was then stationed in another state and Mary, her mother, and her 6-year-old sister visited him approximately once per month.

The mother reported that the patient's controlling and defiant behavior started soon after her father moved to another state. After 3 months of living apart, the family was temporarily reunited during the summer. During the 3 months that the family lived together, Mary's behavior did not improve. Approximately birthday, months before Marv's 4th she began pre- school. One month after starting preschool, Mary began to demonstrate her withholding behavior. Several weeks after the emergence of the withholding behavior, Mary's father was deployed to Bosnia. The patient's mother reported that the patient was easily toilet trained at the age of 2½. She continued to wear a diaper to bed at night as she infrequently urinated when asleep. However, at the age of 4 the patient started to purposely withhold her bowel movements. She regularly refused to use the toilet at home or in school for a bowel movement. She subsequently became constipated and had some episodes of leaking stool in her underwear during the day. The patient was initially seen by a pediatrician who ruled out any medical cause of the encopresis. The pediatrician prescribed a regimen of milk of magnesia and mineral oil for treatment of the constipation. Although the patient's constipation improved with this treatment, she continued to willfully withhold bowel movements and continued to have leaking stool.

When interviewed, the patient's mother revealed a 7-month history of controlling and defiant behavior with her at home.Arguments with the patient's mother would frequently escalate to a temper tantrum in which the patient would throw her toys. According to the patient's mother. these behaviors predated the encopresis by several months. The patient did not demonstrate any evidence of a mood disorder or any evidence of a developmental delay. She was a very verbal child who, according to her mother, had many friends in the neighborhood and at school. The patient's mother denied any separation problems when the patient was dropped off at school each day. The patient's mother also denied that the patient had any behavioral problems at school other than refusing to have a bowel movement while there. The patient apparently also got along well with her 6-year-old sister.

The mother reported that Mary was very controlling of her behavior. Mary would frequently tell her mother what to eat, drink and what clothes to wear. Mary would also try to tell her mother when to get off of the telephone. If her mother did not comply with her wishes, Mary would throw a temper tantrum. Mary did not engage in behavior to control her father's, sis- ter's, or peer's behavior. Mary's mother reported that she was inconsistent in responding to Mary's wishes. She explained that if she were out in public with Mary she was more apt to comply with her demands so that she could avoid a public. Over the course of the next several months. Marv's mothe was instructed to be consistent with her punishments. which consisted of brief time-outs. She was encouraged to give Mary a time-out whether she misbehaved at home or in public. With consistent limit setting.

Mary's tantrum behavior lessened; however, she continued to be controlling and defiant with her mother at home. What is your professional opinion about the prognosis for the case?