Bipolar Children and Poo Smearing

I've read through a number of books on bipolar children. They all seem to have one brief paragraph somewhere in the book that says something about bipolar children urinating in inappropriate places and/or smearing feces. That's it. One brief statement and they're done. The really comprehensive books may say something like "Little is known about this." That's about all they say on the subject.
Yes! I know he does that! Why?! and more importantly HOW DO I DEAL WITH IT?!!
Well, after much research, I'm still coming up empty handed, so here's what we're doing. Maybe this will be helpful to someone else out there dealing with the same thing, or maybe one of you will post here about a good technique you've tried. I should probably also mention that it isn't just poo. He also pours urine in his heat vent, on the carpet, on his bed, in the window sill, etc. Poo he hides, plays with, or smears on carpet, walls, bedding, windows, curtains, and toys. At this age he rarely has much on his body. It's everywhere else.

Poo smearing can be for 4 main reasons: sexual, attention, sensory stimulation, or defiance. I'm lumping anger in with defiance for the sake of simplicity.
The approach to treating the first 3 is much more straightforward, so I'll touch on them because it makes sense to consider those strategies first. I believe Pajama Monster is the last category.

Sexual: In some cases a child who has experienced sexual abuse will act out with elimination issues such as fecal smearing, soiling themselves, bed wetting, etc. In these cases it's obviously the abuse and not the elimination concerns that you want to be addressing. In these cases the behavior is often also accompanied by other symptoms such as sexualized behaviors, tantrums, nightmares, and possible avoidance of the person abusing them. If you think this could be what you're looking at go see a therapist, and prevent unsupervised contact with anyone who had the chance to abuse, at least until you've had a chance to figure out what is going on. This is a case where discipline isn't the answer. This child needs protection and safety to talk about what has happened. Seek the help of a professional and be sure to avoid planting any ideas in your child's head about what you suspect might have happened with leading statements. Not all poo smearing has anything to do with abuse, but I thought I should mention it because it does sometimes happen.

Attention: This one is just straight up behaviorism. Don't provide any response (I know, I want to scream too!) and provide lots of praise and attention when the behavior is not happening. Have the child clean up as much as is developmentally appropriate, but don't clean with him/her because you're trying to minimize attention. Provide a consequence for the behavior but don't comment on it more than to assign the consequence, and make it clear that there are rewards to be had for those who do not do this behavior. It usually extinguishes fairly rapidly once you're not reinforcing it. The reinforcement is your big reaction. ("Rapidly" meaning about as long as you've been reinforcing it, plus a week or two.)

Sensory: These kids are doing it because the texture, feel, smell, etc. is very reinforcing. It feels great to them to squish things between their fingers or smear it on the wall. For these kids you want to provide a sensory appropriate outlet. Painting with shaving cream on the shower wall or a big piece of paper, washing plastic dishes with lots of gentle soap, play doh, finger painting, paper mache, water play, etc. Continue to do your best to limit chances for poo play and provide appropriate alternatives/redirect. Offer sensory play often, and coach the child on ways to ask for sensory play so they don't get the idea that smearing poo is the way to get to play with shaving cream.

Defiance: This one is where we are, and where I suspect most of the bipolar children are. Pajama monster uses a sock or cloth to grab the poo so that he doesn't have to touch it. He also doesn't always smear it. Sometimes he puts it in his dresser, or in a toy, or in his shoe. This tells me it's probably not sensory. He isn't left alone with anyone except daycare, and I've interviewed children and parents from the daycare, and can pop by at any moment to check on him. He also isn't showing any sexualized behaviors, so this tells me it's not sexual abuse. I've tried and tried with the behavioral route. The behavior doesn't respond at all to rewards or consequences. I can literally offer him a choice between pooing on the walls and having a day of scrubbing his walls, or just playing with his toys during quiet play time and then having a treat and going to the park. He picks poo almost every time. There's no lack of consistency with the rewards and consequences. they simply don't seem to have any impact on his behavior. Since I can't make him stop, and this has been going on for several years now, here's what our coping strategy had been, followed by a discussion on our new strategies and the role of anger in this behavior:

1. We stripped his room of everything but a washable toddler mattress and blankets and a couple easily washable toys.
2. I got a carpet shampooer. If I had the choice I'd just have linoleum in his room.
3. I painted his room in high gloss paint (He got to choose the color...light blue.)
4. I tied his ability to choose his own food and have treats to whether he'd smeared poo/urine in the past 24 hours. (I hate to use food as a reward/consequence, but I'm kinda desperate and I wanted to show that he could have more control if he's made good choices.)
5. When he smears poo I calmly remove any remaining large pieces and give him a scrub brush and a couple of wet cloth diapers and tell him he may come out when the room is clean. Without saying anything else I then shut his door and return periodically to check progress. If progress is made, I praise the effort and leave again. If no progress then I just shut the door. Once the room is clean (anywhere from an hour to a day and a half so far)to 4 year old level of capability, I have him sit in a chair till I finish cleaning. He doesn't get to sit with me or interact with me or play during this time. Once I've shampooed out any bad spots from the rug and wiped off any residual from the walls, he may wash up and return to normal life. Obviously he gets to come out for meals and school and doctor appointments whether he's cleaned up or not.
6. We have a toddler potty in his room so that he doesn't get creative in the main bathroom/ hall/ rest of the house after bedtime. It also prevents the "I have to go potty" every 5 minutes battle we used to have at bedtime. He'd spend 20 minutes playing in the bathroom and then would announce he needed to potty as we were putting him back in bed. If we didn't let him return to the bathroom he'd poo or urinate on his floor, despite having spent the last 20 minutes not using the toilet in the bathroom. If we did let him, the cycle would just continue over and over.
7. I keep a small jar of the paint for his walls and a paintbrush handy to do touch ups when he manages to damage the wall.
8. When he was younger we used several strategies to keep him in a diaper. We would put him in footy jammies that were pinned shut with a diaper pin, not a safety pin. Diaper pins have plastic covered heads that are less likely to come open on their own and poke the child. When the pin didn't work we moved to cutting the feet off the jammies and pinning them on him backwards, or even wrong side out and backwards. These helped for a little while, but my son can disable any childproofing device and nothing will stop him from getting out of his clothes now.
9. I explain the natural consequences of his action, such as no friends can come over because the house smells like poo, or we can't go to the park because Pajama Monster needs to clean, etc.
10. Minimize his chances to do it. Lots and lots of supervision seems to decrease his opportunity. I am especially careful when he uses the bathroom or at bedtime. This doesn't always prevent it because I can't be there all the time, but it does reduce it somewhat.
11. I put a cotton cloth about 2.5 feet down his heat vent. He can't reach it there but it will soak up any urine, etc. that gets dumped down there and prevent it from getting deep into the heat ducts where I can't clean it but will have to smell it every time we run the heat.
12. I make sure that the process of cleaning Pajama Monster isn't reinforcing. He gets any soiled parts of himself rinsed off with cool water from the shower sprayer, then quickly dried off and back in his jammies. We don't do the usual long toy filled bubble bath that he enjoys so much or else the smearing behavior just becomes a way to get a bath, thus reinforcing it.

The new strategy: We're using many of the same techniques with two noteable exceptions. We're no longer having him clean alone over whatever length of time it takes him, and we're no longer tying other consequences after the fact. I'm still expecting him to clean, but if he's not cleaning then I hold his hand and guide his cleaning till everything is done, then we wash up and move on with our lives. I'm not sure if this will work yet, but at this point all I know is that what we were trying wasn't working and I'm not willing to spank him (and also don't think that would help) so that leaves us with this.

When a child behaves this way, and it isn't sexual, attention, or sensory related there is usually an underlying anger component. I know this from my years in the field, but what I don't know is why Pajama Monster is mad. Usually I see this when the parent is on meth and neglecting/abusing the kids or there's some sort of extreme emotional abuse, but we have a pretty normal family, and I suspect most of you reading this do too. Pajama Monster is consistently praised and told that he is loved. He has toys and education and playdates and snuggles. The things that seem to make Pajama Monster angry always center around control, and they're unfortunately usually things I can't give in on. We give Pajama Monster age appropriate levels of control, and choices on almost everything else. I'm willing to problem solve and negotiate, but sometimes I just have to say "No." No, you can't take your sister's ice cream. No, you can't play with the electrical outlets. No, you can't have a sharpie. If I were my own client, the first thing I would be looking at once determining the anger issue is how to give Pajama Monster a sense of control, but in Pajama Monster's case there just doesn't seem to be enough control in the world to satisfy him. If he wakes on his own time and picks his clothes and breakfast and fun activities and lunch and generally has free range to make his own choices, he'll melt down because his sister got to pick the pink bowl and he wanted her to have the blue one (We have multiples of each color. He didn't want pink. He just wanted to make her choices for her.) If I structure his day so that everything is nice and predictable for weeks and weeks at a time, he still gets mad every time a choice isn't his, and doesn't seem to care about the routine at all. I feel like I'm trying to fill a bottomless pit of need for control, and as long as it isn't full there will be anger bubbling out of it. I'm hoping that by switching to a "fix it and move on" strategy perhaps I can minimize the anger a little bit and also break the long stretches of time that Pajama Monster is dealing with poo.

Just in case anyone out there was wondering, I should probably also mention that there was nothing strange about Pajama Monster's potty training. We offered praise and rewards and never gave consequences around toileting. He was given a potty at about 18 months and allowed to use or not use it. It was just there in the bathroom when he felt ready. He was around 3 years old when he was done with diapers, but still wearing a bedtime diaper because he still wets the bed. He's never been scolded for bedwetting. We give him control over age appropriate things such as what he plays with, what he wears and what he eats (within limits of course-no marshmallow and chocolate dinners!). I truly don't know where this behavior came from, but it's been a long and very frustrating struggle.