Jennifer—The central definition of encopresis is behavioral, not “medical.” Often much effort and expense is expended in “ruling out” physical causes leaving 90-95 per cent of children with the essential problem remaining.  This is why it is termed a “functional disorder.” This often frustrates parents and doctors, who want a clear cut physical cause.  However, physical factors do come into play.  Encopresis is simply defined as soiling once a month in inappropriate places after age 4 years.  So if she still has fecal accidents you have encopresis.   Yes, the “holding it in” issue can start for almost any reason, but pain is often a major factor as our muscles tend to contract in response to pain and psychologically we avoid pain.  Once the holding response becomes “over activated” or “over conditioned” to voiding signals it just becomes automatic and less subject to willful control.  An enlarged colon or mega colon then results which results in physical inefficiency for pushing the foodstuff along.  The holding response simply will not give way to the voiding response which should follow.  Hence, your insight about a “wicked cycle” is right on target.  Add Miralax, a very popular stool softener intended to make stool passage easier, and you add a much greater likelihood of accidents because the stool becomes too soft and “liquidy” and harder to recognize by the body.  Normal hot dog like stools are much more easily detected at the end of the colon, but now you have the problem of the “over holding” predominating again.  There is no way around it, the actual voiding response has to be retrained to become more dominant and assert itself over the holding response.  Your doctor is assuming, like the vast majority of them do, that the voiding reflex will have a fresh automatic “restart” and take over again.  I hope he is right, but that may be only 40-60 per cent of the time at best.  Allergies and diet factors come into play in only 5 per cent of the cases of encopresis.  I encounter a lot of parents going into elimination diets, adding certain foods, etc. in hopes of “magic” happening.  My Soiling Solutions (SS) protocol set forth in the Clean Kid Manual (CKM) has received international attention, but it is still very strongly resisted because it involves the use of suppositories and enemas in a carefully stepped fashion designed to foster the child’s own cues and the appropriate coordinated holding and voiding responses to take over.  I wish you the best of luck, but definitely do not ever let this problem persist to 6 years of age.  Many parents can’t stand it going on for that long, but too many do out of fear and their own inhibitions about dealing definitively with this area of the body.  If you continue reading you will see horror stories about how very ordinary parents get trapped.  Do not buy into a physician’s assurance that your child “will grow out of it.”  Take control of this issue, your child may resist strenuously, but she will be grateful that you are truly parenting and acting in her best interests.