Any dedicated, committed parent will tell you that toilet training a toddler can be quite the journey. From choosing the ‘right’ time to start, to picking the ‘right’ potty, shopping for the ‘perfect’ undies, choosing the ‘best’ toilet training book – the list is endless. As we know, even typically developing children will often take a ‘two steps forward, one step back’ approach to toilet training. We persevere (with wine to help us) and eventually, most children ‘just get it’ and toilet training becomes another early development milestone to tick off the list.
Every now and then, one of your friends might report that their child is ‘a little constipated’. Your child might have skipped a few days passing a bowel motion and feel a little listless. We usually nod and quickly dismiss the topic and put it down to picky eating (what 3-year-old likes vegetables?), smuggle some prune juice in their milkshake and it’s back to normal.
Did you know, however, that there is a much more complex issue that presents like ‘regular’ constipation but requires a different treatment approach?
Imagine Your Biggest Fear:
Imagine your biggest fear. Let’s say it’s a fear of heights. Would you like to talk about it with others? Probably not. Would you like to live on the 25th floor? No way. If your friends were going hang gliding, would you go or make up an excuse to avoid it? Imagine if you were told that you HAD to go hang gliding after dinner every single day. No doubt you would feel quite worried or scared and perhaps even experience physical symptoms such as a racing heart or feel the urge to ‘run away’.
Introducing “Stool Withholding”
For some children, both typically developing and those with additional needs, pushing out a bowel motion is like facing their biggest fear. Every. Single. Day. What do these poor children do when they feel a poo is on the way? They react the same way as adults do when faced with their biggest fear – they try to avoid it.
Introducing the term ‘stool withholding’. Simply defined, stool withholding refers to holding in a bowel motion instead of passing it out of the body (Ferguson, 2015). If done for long enough, stool withholding removes the “urge” to poo. The child then feels short term relief that they have avoided their fear. The child then repeats this action the next time they feel the urge to poo. This vicious cycle then causes a build-up of old, hard stool in the colon, which then presents like constipation.
Why Does Stool Withholding Start?
It can be difficult to pinpoint an exact “Day Zero” for the onset of stool withholding. For some children with additional needs, stool withholding may be due to underlying conditions relating to developmental delays, sensory challenges or language disorders.
For other children, Ferguson, (2015) identified three main trigger points that may cause the onset of stool withholding:
· A painful experience pushing out a bowel motion – quite possibly from a case of garden variety constipation!
· The commencement of a new childcare or education environment, such as commencing daycare or kindergarten.
What Can Stool Withholding Look Like In My Child?
Whilst every child is different, there are some subtle signs that your little one may be experiencing fear around pushing out a bowel motion:
· Fear of using the toilet or potty
· Hiding when asked to use the toilet or potty
· Soiled undies, either small stains or whole bowel motions
· An increase in wee accidents, as the full colon is pressing on the bladder
· Physical signs such as stiffening the body, crossing their legs or turning red-faced to attempt to hold in their poo
How Do You Treat Stool Withholding?
Unlike regular constipation, which is purely about managing the physical symptoms, stool withholding requires tackling the underlying emotional issues. On a physical level, your GP or Paediatrician can provide education around administering laxatives for your child. This will help to keep the stools soft, making them easier to pass.
Tackling the Emotional Issues:
Tackling the emotional issues around stool withholding are crucial to moving forward. Try the following:
1. Focus on pushing out the poos – not toilet training: If your child is withholding, going back a step to focusing on pushing poos OUT can be very helpful. For now, at least, pack the potty away and forget the toilet – passing bowel motions in these places are LONG TERM goals for your little one. Start by supporting your child to have repeated exposure at pushing out pain-free poos. This can be into a nappy or a pull up standing up, or whilst wearing undies – anything that helps your child feel at ease.
2. What rewards will work? Find your child’s internal motivator – is it that new box of lego? A pretty barbie doll? Create a “Points Chart” with your child – for every poo they push out, they get 5 points on their chart. When they reach 15 points, they get that reward.
3. Use a social story: Social stories are simple stories personalised for your own individual child. They help to explain different procedures and social situations in simple, everyday language. The social story below “I Can Push Out My Poos” (Australian Version) or “I Can Push Out My Poop!” (American/ UK version) uses a story to examine stool withholding in a gentle way, helping you to start the conversation about this issue with your child.
Stool withholding in children is a confusing, silent condition that can be extremely challenging for families to navigate. The good news is that there can be light at the end of the long, dark tunnel and with the right resources, we can help support our little ones to feel calm, feel safe and ultimately thrive.