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July 2014

Enemas as Incentives to Cooperate

Positive incentives such as stars/stickers on a Good Pooping Chart, time on the computer or small pieces of candy (e.g. M&Ms) are almost always necessary to get children to cooperate with the long-term treatment of functional constipation. However, I have found that some children reach a point in treatment where positive incentives alone are not enough. With these children I will sometimes recommend a negative incentive, telling a child that they will be given an enema if they do not poop by the end of the day. The following is a case in point:

“Thanks for recommending that if Peter doesn’t poop we give him an enema. That advice worked great as that night his dad put the enema on the bathroom counter and said, “It’s ready to go if you don’t poop” and, viola, Peter pooped right away. I have had to do the same thing a few times when I can tell he’s not really trying and it always works. Ever since the day we started doing this Peter has been pooping consistently every night. We still need to tell him to go but he does poop on the potty.”

Reward Charts Need to Be Visible: Q&A with Dr. Tom

In previous posts I have emphasized the need for sticker charts and sometimes (inexpensive) rewards to help motivate children to actively participate in their treatment.  The following Q&A speaks to the need for charts and rewards to be public and to reward the the behaviors required to achieve a treatment goal as well as the goal itself.
Mother: "Thank you so much for your sound advice.  I am using the reward chart as you suggested and marking it on my own & keeping it in a drawer with his poop record & he earned a big reward yesterday.  He is feeling good about himself but we had a big struggle to get him to SIT on the potty after breakfast.  He wanted to stand only which is one of our biggest struggles."
Dr Tom: I recommend that you bring the incentive chart out of the drawer so he can see it. Recall that he gets stars, stickers, etc for doing those things which will increase the likelihood of having quality BMs as well as for having them. Therefore, his chart should start with going to the bathroom cooperatively (allow a little resistance at first) followed by sitting and pushing (at least twice per instructions in my book). Having a BM is the last thing on the list. He gets small prizes (eg an M&M) for each of the first 4 steps and a larger prize for the BM (eg 4 M&Ms or whatever you are giving him now).