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December 2019

Fear of Pooping: Treat With "Exposure Therapy"

The fear of pooping is like a phobia. Parents will often ask why their child continues to be afraid to poop and, therefore, refuses to poop even after their child's poop stops hurting. Continuing to fear pain in the absence of pain seems irrational. Although there was a reason to be afraid in the past, that reason no longer exists. Just like a fear of bees can persist long after the first sting, the fear of pooping can persist long after the first painful poop. Such fears require treatment with exposure therapy.

In exposure therapy, phobic fears are neutralized by gradually and repeatedly exposing people to the object or the situation that evokes that fear. In the case of a fear of pooping, the child's fear of pain decreases little by little each time he passes stool and does not experience pain. The number of pain-free bowel movements needed to neutralize or extinguish the fear varies from child to child depending on various factors such as the age at which constipation began and the child's current level of maturity and cooperation.Regardless of these individual differences, however, the number of painless bowel movements required is always going to be large, which is why the treatment of functional constipation takes so long.


Children Who Withhold Poop Are Afraid It Will Hurt

Children who experience pain or discomfort when pooping quickly learn to withhold their poop because they are afraid that the poop will hurt. They learn that the pain or discomfort can be avoided by simply contracting the muscle (sphincter) around their anus whenever they feel the need to poop. Withholding begins as a voluntary response (a conscious decision), but if the painful or uncomfortable bowel movements continue, withholding can become involuntary. This means that the anal muscle "closes" automatically whenever the rectum contracts which is what causes the feeling of urgency, the need to poop. Withholding is no longer a conscious decision. It has become a habit which leads to functional constipation--also called encopresis.

Exactly how long it takes for withholding to become a habit varies with age and temperament. Some infants and children begin to withhold involuntarily after just one painful or uncomfortable bowel movement whereas others are able to tolerate a number of painful bowel movements before becoming habitual withholders. The difference between the two groups is most likely related to the degree of discomfort or pain they experience. The more intense the discomfort the more quickly withholding becomes involuntary.


Explaining Encopresis to Teachers

When enrolling their child in a preschool, kindergarten or first grade class, a question parents frequently ask is "How do I explain encopresis to teachers?

The first thing to do is ask the teacher (and school nurse) what she or he knows about encopresis. If nothing or very little, suggest that the teacher or nurse read my book, especially Chapter 19 titled, "Encopresis Goes to School" so that you and the teacher are both on the same page (literally and figuratively!) about what encopresis is and what it is not. For example, some teachers may think that children who have poop accidents are able to control when they poop and that, therefore, poop accidents are intentional. Providing your child's preschool or kindergarten with accurate information about encopresis at the beginning of the school year will prevent a lot of misunderstanding and stress for you, the teacher and your child.

You should arrange with the teacher to have a change of clothing available at all times in case of an accident. If soiling is frequent, you may want to send a change of clothing every day. If infrequent, one change of clothes left at school may be enough. You should also ask the teacher to allow your child to go to the bathroom whenever she needs to go rather than telling her to “wait” or to “hold it”. Whenever possible, your child should be allowed to use a one-person bathroom like the one at home. Children with encopresis are often unwilling to use a bathroom that is not “private”.


Teacher Punishes Child For Soiling In Preschool

I met this child and her parents in my office two weeks after her preschool teacher had told her parents that she "would quickly stop soiling once she learned that no one was going to help her clean up." The teacher also recommended that the girl be given a backpack to take clean clothes to school and soiled clothes back home. Not surprisingly, this girl was very unhappy  and was having even more trouble with soiling than she did before. 

My first order of business was to speak directly to the teacher to explain encopresis. For children with encopresis, soiling is not a choice.

Parents of children with encopresis (functional constipation) get this kind of advice from all sorts of people: friends, grandparents, daycare and preschool teachers and even healthcare professionals. This “rub her nose in it” advice is based on two erroneous assumptions:

  1. She is able to control when she poops.
  2. Her poop accidents are intentional.

Following this kind of advice inevitably causes shame and embarrassment especially in the classroom. And, as any parent with older children knows, once teasing begins at school it is difficult to stop.

Telling a preschool child with encopresis to clean herself up without help is almost always perceived as punishment, and, as I explain in my book, The Ins and Outs of Poop, punishment is almost always counterproductive. It becomes especially punitive when the accident is large and messy. While I think it’s good to have children HELP with the cleanup as much as they can (e.g. by dumping their poop into the toilet and/or by flushing), they should not be made to do it all by themselves.

Poop accidents can be eliminated through a combination of laxatives and POSITIVE incentives, but most critical is your attitude and willingness to help the child, as well as the attitudes of those other adults she admires and looks up to.