Editorials for Clinical Practice
CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.
Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.
He just won’t poop
One of the problems that evoke consternation in doctors and parents alike is stool refusal in an otherwise normal child. While you may be completely comfortable solving problems of encopresis in school-aged children, the recalcitrant preschooler who will urinate in a toilet or potty chair but simply won’t deliver a poop there brings parents to their knees. They imagine their dreams of Harvard going down the drain – instead of the stools that belong there. On a more practical level, that pricey deposit for preschool, or any preschool attendance at all, appears to be on the line, making parents do desperate things.
The usual scenario for stool refusal is a bright 3- to 4-year-old who has succeeded in using the potty a few times and then simply stops using it for stools. Urination in the toilet may or may not continue, but when it comes time to defecate, the child either hides behind the sofa or demands a diaper.
Sometimes stool refusal presents with the child assuming an arching rigid posture. This has brought families to me as a consultant with concern about possible seizures or other serious medical conditions such as a bowel stricture. It looks to the parents as though the child is trying his best to get the stool out when in fact it is a valiant effort to keep it in.
The reason this syndrome is called stool refusal instead of encopresis is that it occurs only in children younger than the cutoff of a mental age of 4 years. While you might consider this a failure of "toilet learning," these children understand completely what is expected of them in the area of using the potty. They show this knowledge and the presence of the neurological integrity needed to control voids by successfully urinating in the toilet.
How much easier it would be to just finish the job! What are they thinking?! Thinking is exactly part of the problem in stool refusal.
Some children develop stool refusal after having a painful poop due to constipation, diaper rash, or diarrhea. It seems that they decide, "Well if it’s going to hurt, I’m just not going to poop anymore!" The subsequent withholding of stools then makes them harder, larger, and more painful, confirming their fears and strengthening their determination. Logical arguments about the inevitability of defecation do not prevail with preschoolers.
Sometimes stool refusal develops during that predictable period of oppositionality around 2 to 2.5 years. Anna Freud – yes, indeed, the daughter of Sigmund – was interested in the development of toileting control, and described one of the essential ingredients to toileting success as being "the child’s desire to please the parent." She even wisely recommended that teaching this task should not be undertaken when the child is in a phase of resisting every other command the parent makes! This advice is often forgotten in the urgency of the mother’s desire to return to the workplace or enroll the child in a, particularly desirable daycare. As the famous Dr. Barry Zuckerman points out, the anus is one of the "five orifices only the child can control" (two eyes, one mouth, urethra, and anus). If there is to be a control battle between parent and child, going to sleep, eating, and voiding are likely to be the battlefields.
The child’s own ideas about growing up are often captured in this huge social milestone. Parents may even feed into the refusal by exhorting the child to be a "Big Girl" and use the potty so that she can go to school when the child herself would much rather stay home with mommy!
Some children develop a fear of the toilet after a scary slip inside a seat not designed for tiny buttocks or when the automatic flush mechanism at a public restroom triggers a torrent (which is easily avoided by placing a sticky note over the electric eye).
Some children suddenly refuse to poop in the toilet as they become aware that things that go down the toilet never come back. That is one reason they are fascinated – or even obsessed – with flushing the toilet over and over again: It’s like watching a horror movie. And they are being asked to take that lovely poop, apparently so treasured by parents and grandparents as to elicit praise and presents, and make it disappear!
And not only that, the process of toilet learning occurs right at the age when toddlers look around them and notice gender differences. This is more striking when there is a little sister co-bathing or when parents go naked with the child present. And the little boys can’t help but see that half the population has lost their precious penis. Where did it go? No wonder they hang onto it. At 3-4 years of age, children do not understand about possible and impossible transformations. The disappearing turd certainly suggests its terrible fate.
Understanding which of the factors just described are at work is key to resolving stool refusal. The first rule of thumb is to assume that constipation was either a contributing factor or has occurred secondarily, and to aggressively give laxatives aiming for at least two inevitable stools per day. It is important not to have any more painful stools, and it is also easier to retrain a more common occurrence. I use Miralax powder, usually, 1-2 tbsp, dissolved and allowed to sit for 10 minutes in any desirable drink, which is then given at bedtime. Inform the parent that the dire warnings on the label about chronic use do not apply to their child. Continue the laxative until stooling in the toilet is completely without a struggle.
For the other causes, taking a regular history of daily functioning – such as mealtimes, bedtime, separations, sibling aggression, or regression – will usually reveal the dynamics, whether they are control issues, sibling jealousy, fear of the toilet or of school, or general attention-seeking. Translating the hypothesized dynamic to the parents is terribly important to acknowledge the meaning the child and often the family has given this behavior.
In the case of fear of falling in, using a potty chair firmly planted on the ground, and then progressive desensitization, practicing sitting while clothed, reading stories about toileting, and maybe a toilet scrapbook will gradually work as long as the child is not pressured.
To reassure about nurturance, instituting "Special Time" will help with sibling jealousy. This is also crucial when stool refusal is occurring with attention-seeking as the cause. I also recommend encouraging "infantilizing" during Special Time. This might mean offering a pacifier, feeding the child with a spoon or bottle, holding him or her in loving arms, and talking to them in baby talk. These instructions often meet with shock, especially from the parents who need them the most, as they directly confront their fear that this child will never grow up! It is extremely powerful for a parent to show, as well as tell, their child that "You will be my baby forever." All children have a strong drive to grow up, but some need this reassurance that growing up does not have to mean losing the safety and nurturing they associate with being an infant.
When power struggles appear to be the problem, it is best to put the child back in diapers all day while the parents work on a more appropriate balance between control and nurturance. Panties are a privilege to be earned. Using cloth diapers can make this step more effective as they are less comfortable when soiled. Be aware that the child is likely to revert to urinating as well once in diapers, but this does not require any different management. The parent and any other caregivers must show no emotion when the child soils or wets the diaper, but neither should they be in a hurry to change the child, instead of postponing this attention for at least a few minutes. When they do clean up, it should be done silently and with neutral affect. This process helps remove any secondary gain that stool refusal was providing.
To address the child’s opposition, more work may be needed. The first step is usually reducing the number of demands the parent gives the child each day but following through on each command by physically moving the child to do the task after only "one request." If parents are interfering with each other’s management of the child’s behavior, this should be corrected as well because the toileting dysfunction may be a reaction to tension in this dynamic.
Given that boys, in particular, may have the penis anxiety described above, I always reassure them with my "Penis Talk" that "boys are made with a penis and girls with a vagina. When you get big like daddy, you will have a big penis, too. Your penis cannot fall off, and no one can ever take it away."
As part of normal toilet learning, children should be taught to recognize the feelings they have when "their poop or pee wants to come out." We do not need to teach a child to think of their feces as having feelings since animism comes naturally! The additional information I add is about the desire of their stools to attend the "Poop Party under the house! Poops can only get there when passed into the potty chair or toilet, though, not by being dumped in from the diaper as some clever children may assert. I then turn to the parent to ask, "Do your poops go the Poop Party?" providing a knowing wink if necessary. But sadly sympathize with the child that, "Too bad, your poops don’t get to go." Suddenly, doubt has been generated in the child about their choice to withhold!
If the child does not ask to use the potty after several weeks of really implementing these techniques, having several soft stools per day, and having previously shown the understanding and ability to use the potty, the method of room restriction can be used. In this method, the child is restricted to one room of the house, perhaps naked, along with a potty chair starting half an hour before the time that has been determined to be typical for a stool to occur. In the room, the child can play but should not get special attention or use any electronics, and cannot leave.
Once the potty has been used for a poop, he will be free to leave, go outside, and have other privileges for the rest of that day until the next scheduled stool. If he instead poops in his diaper, he continues to be restricted for the rest of the day. This plan is continued until the child is successful, which usually takes no more than 3 days.
Typically, the above approaches (not including the need for room restriction) will result in a child requesting to use the potty or toilet within 2-3 weeks. It is critical to coach all caregivers to act indifferent to this request, shrug, and say, "Okay, if you want to." Once a child does what they experience as conceding to using the toilet, there should be no prizes, calls to grandma, or celebrations as these can cause a reversal of the child’s willingness to show autonomy in this function. After all, it’s his poop!
Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at firstname.lastname@example.org.