Today’s Blog post is a little different to our regular articles – I sat down with the VERY talented Tabitha, Occupational Therapist from @toilettimewithtabby to dive into ways that an OT can help children experiencing stool withholding and constipation. What a great discussion!
Melissa: Tabitha – thanks so much for joining me for this interdisciplinary discussion on stool withholding! It’s such a big topic and I think one of the challenges that parents face is when their child is withholding their poos and it leads to constipation, parents don’t know WHAT to do but they also don’t know WHO can help them – which is why I was so pleased when we connected on Instagram!
Tabitha: Thank you for having me!
What is an Occupational Therapist?
Melissa: So Tabitha, let’s start off by telling everyone what it is that an Occupational Therapist is and specifically what your focus is in your work with families:
Tabitha: Occupational Therapists help people do stuff. Important, daily, meaningful stuff! I focus on potentially the most important, daily, meaningful stuff – poos and wees.
This means I literally talk sh*t for a living! I help children, families and even some adults, to manage their continence needs. I practice as a AHPRA registered Occupational Therapist in Perth, Western Australia, and provide advice and support to families as a continence consultant in Miami, Florida.
Toilet Training, Stool Withholding & Constipation
Melissa: I love that you focus on wees and poos for a living! I’m curious (and I’m sure many of our community are too!) as to what your journey looked like to bring you to where you are today? What sparked the interest to focus on toileting in your career, rather than other areas of Occupational Therapy?
Tabitha: I worked in a generalised paediatric role in the disability sector, and had many children with toilet training difficulties on my caseload. Whilst I knew toilet training basics, I had no idea about stool withholding and constipation, and was wondering why my timed toileting programmes, sensory strategies, dietary suggestions and equipment recommendations just weren’t working for my clients.
At this time, I was lucky enough to work alongside a specialist, multidisciplinary continence team called PEBBLES in Western Australia, and started to refer my clients to this service. I saw the work they did and they were like wizards! The children I referred to their service would not only have their toilet training/continence issues resolved, but would come back to me happier, healthier, more regulated, developing better communication skills, trying new foods, and I saw the huge positive impact on the whole family.
I decided to take a 12 month secondment with this team, to learn about this wizardry myself, and that is when I fell in love with the field of continence management. 8 years later, I have started my own practice to help children and families with their conscience needs from all over the world!
Continence doesn’t just impact the individual, but the whole family. I love nothing more than to hear a parent say that they can now go camping as a family without fear of a “code brown” in the tent, or that their child is excited to go to school in underwear, and isn’t scared of accidents anymore.
What does stool withholding look like in children?
Melissa: I agree with you so much that constipation affects the whole family and can stop a family from enjoying life at times! So in your work with families, what is stool withholding behaviour? What sorts of things might our children present with if they are withholding their poos?
Tabitha: Constipation is the number one reason preventing the children I work with becoming toilet trained/continent. Often constipation is very sneaky and doesn’t look like constipation at all. Children are great problem solvers, and sometimes when they have experienced constipation, or even are just too busy to go to the toilet, they “put off” doing a poo which can start a pattern of behaviour leading to stool withholding.
This might look like delaying going to the toilet, maybe they don’t like doing a poo at school and would prefer to wait until they get home. There can also be physical signs – crossing legs, squeezing glutes, laying prone (tummy down) on the floor, pressing their heel into their bottom or raising up on tiptoes.
Withholding can also be sneaky, and there may be no physical signs, but the child may become dysregulated, not want to eat, have stomach pain, headaches, irritability, nausea or just seem “out of sorts”.
Over time, withholding can become almost reflexive – children feel the need to poo and before they can even think about what to do, they are holding on. The anal sphincter muscles are like other muscles in your body – if you exercise them, they will get stronger.
Related: Why is My Child Struggling to Poo? Top Tips for Stool Withholding
How Can an Occupational Therapist Help a Child with Stool Withholding?
Melissa: Breaking the vicious cycle of stool withholding must be such a challenge! So how can an OT help with toileting and paediatric constipation?
Tabitha: The first step is always to gather data. We can’t change what we don’t measure! Taking a comprehensive history and getting a thorough bowel diary (for 1-2 weeks) is a great place to start. ERIC (the children’s bowel and bladder charity in the UK) have fantastic free, printable resources for health professionals to use. I also love the “Happy Poop” app.
If constipation is identified, the next step would be to advocate for the family to seek medical assistance from their GP, pediatrician or primary physician. Whilst I speak to families about medications and medical procedures (almost) every day, it is important for all OT’s to practice within their scope and ensure that the medical professionals are kept in the loop about all potential treatment plans.
Once constipation is treated, then OT’s have so many great skills to help children and families set up the toilet environment, routine and work on skills such as interoception and self regulation. Having an understanding of the biomechanics related to optimal toilet positioning and a client-centered approach to the task will help the family achieve success. I say “family” because often toileting requires a whole family, or even community approach! Going to the toilet happens several times per day, in different environments and often, with different people supporting. Relaxation strategies, making the activity fun (and less scary), supporting children’s understanding of what is happening inside of their body is all within the scope of an OT – no wonder I love this job so much!
The best, evidence-based interventions involve a multidisciplinary approach to continence. Referrals to dietitians, physiotherapists, nurses, speech pathologists, psychologists and other allied health is encouraged!
Poop Withholding Advice for Families:
Melissa: I definitely love a team approach too! What is your top tip for parents who have a child struggling with stool withholding or constipation?
Seek professional help, and if the first professional doesn’t give you a satisfactory answer/support plan, continue to seek help.
Constipation and stool withholding are really common. About ⅓ of all children will experience constipation at some point in their lives. This doesn’t mean that you’re a bad parent, your child is lazy, or you’re doing the wrong things.
Constipation often won’t go away on its own and can have serious health and social outcomes if left untreated. In saying all of this, not all medical professionals know how to manage constipation in line with the best available evidence, so you may need to seek out an expert’s advice or support to effectively manage constipation.
Resources for Poop Withholding:
I would highly recommend ERIC – The Children’s Bowel & Bladder Charity. This is a fantastic organisation that I have recently started working for as an online trainer. They not only have free, printable resources for families and professionals, but run training courses that are evidence based, interactive and a lot of fun (if I do say so myself).
I also participate in affiliate marketing for Squatty Potty Australia. Here are links for some of my favourite Squatty Potty products to support positioning on the toilet.
Squatty potty bamboo flip stool
Squatty potty foldable travel stool
Connect with Tabitha to learn more:
Melissa: Tabitha, thank you so much for joining me today to talk all things constipation and poop withholding! Where can we connect with you to learn more great tips and advice?
Tabitha: Thanks so much for having me!
Here’s how you can connect with me:
Instagram: toilettimewithTabby
Facebook: ttwithtabby
Web: https://www.tabithapoole.com/home
LinkedIN: toilettimewithtabby
BIO: Tabby is an Occupational Therapist (OT) with more than 12 years of experience working in pediatrics. She is based in Miami, Florida, and Perth, Western Australia, and offers video consultations worldwide.
Following the completion of her degree in OT, Tabby continued postgraduate study in the field of continence management, and has worked as an OT across Western Australia, England, and Scotland. For the past 6 years, Tabby has worked in and managed a specialist, multidisciplinary continence team, serving clients across the lifespan with a variety of diagnoses and complex continence needs.
Believing that there’s always more to learn about continence management, Tabby is enthusiastic about continuing her own education to ensure she practices in line with the best and most up-to-date evidence in the field. She also loves delivering training, and has presented at numerous workshops and training events, including the Australian National Conference on Incontinence and is now an ERIC trainer.
