In Chapter 5 of the second edition of my book, The Ins and Outs of Poop, I write that though the majority of children who have encopresis do not have unusual behavior problems, many do. Twenty five to thirty percent of children with encopresis are described by their parents as unusually active, impulsive, inattentive, stubborn and/or disruptive. Most of these behavior problems are manifestations of the child's temperament and rarely rise to the level of a diagnosable condition. Temperament organizes a child's approach to the world. It is the way a child is wired and is a major determinate of how easy or difficult it is for parents to manage their child's behavior.
A child with a stubborn temperament may resist toilet training by refusing to poop in the toilet: choosing instead to withhold stool which can result in functional constipation. Likewise, an unusually stubborn child who becomes constipated following one or more painful bowel movements may refuse key aspects of treatment such as taking laxatives, doing practice sits or "pushing" when sitting on the toilet. Therefore, I often recommend that parents of children with temperament-related stubbornness learn behavior change strategies (that increase compliance and decrease non-compliance) preferably, but not necessarily, before initiating toilet training or treatment for functional constipation (encopresis).
Parents who want to learn these strategies should seek the assistance of a therapist or treatment program that describe their services as "Parent-Child Interaction Training or Therapy." (PCIT) For parents who do not have such a resource available to them, this chapter includes my own detailed PCIT Self Study Course.