Children who only poop in diapers or pull-ups

Parents find it difficult to change the behavior of children who have become dependent on, and will only poop and/pee in a diaper or pull-up.  Treatment of these children occurs in three different phases each of which requires the effective use of incentives (pages 120-122)  and star charts (131-133) as shown in my book:

Phase 1. Teach them to poop/pee in the bathroom while wearing a diaper or pull-up.

Phase 2. Teach them to poop/pee sitting on the toilet while wearing a diaper or pull-up.

Phase 3. Teach them to poop/pee sitting on the toilet without a diaper or pull-up.

The time it takes to successfully complete each of these steps varies with the age of the child, their level of anxiety about pooping without a diaper or pull-up and about pooping in the toilet. Parental patience and a willingness use "carrots" rather than "sticks" are essential. 

The email below was sent to me by a real mom following a telephone consultation regarding her 6 year old son who would only poop in a pull-up. 

Hi Dr. Tom,

I wanted to give you a further update on Kyle’s progress.  Just 7 weeks after starting the strategies you and your book helped us design, Kyle is pooping on the potty every day!  This is a child who could barely tolerate a brief sit on the toilet for over three years!  I am AMAZED by how far we have come.  As I reflect on what really made things work for us, four points come to mind.

1) Book and Phone Consultation. I want to tell you that I literally cried when I read your book.  I was ashamed that my six year old could not poop on the toilet. The combination of reading stories from people struggling as we were, and thinking that your strategies might work for us was powerful.  But I had reached a place of exasperation, confusion, and fear of doing the wrong thing.  I still was not sure exactly how to proceed.

When I discovered that I could purchase a phone consultation through your website, I decided to give it a try.  How thankful I am that I did!  It certainly shows that you have been working with kids like Kyle for 30 years.  You knew things about Kyle that even I didn't.  Your understanding, guidance and support were invaluable.  Perhaps most importantly, you gave me the insight and encouragement I needed to be patient.  Luckily for us Kyle has made tremendous progress quickly, but I got off the phone feeling that even if it took many months that would be OK.  We just needed to take baby steps in the right direction.  It is normal for these kids to progress in such a fashion. 

2) Chart Power.  As you mentioned to me, there is a good reason why the chapter on positive motivation is the longest in "The Ins and Outs of Poop".  Finding the right motivation for your child is crucial.  I had tried charts before, but not designed in the way you describe.  Several small steps, most of which I knew he could either do already or that would be easy for him, was key.  He was still resistant, but that is where the abundant stickers and immediate reward came in.  These were more powerful than I could have imagined.  Seeing the beautiful sticker waiting to go on the chart in the moment after his effort meant so much to Kyle.  He got over the hump of his reflexive resistance to all things potty!  Once that happened and he started to focus on the extra video game time he would earn when his chart was filled, he willingly did his push practice every day. 

3) Miralax.  When allowed his pull-up, Kyle would poop every day or two.  He didn't complain of painful BMs even when I asked him directly if discomfort was a problem.  When I asked my pediatrician about a stool softener, she saw no need due to his regularity.  You assured me that kids like Kyle need Miralax.  Were you ever right!  I started at a low dose and slowly increased as you suggested.  It took longer than I had anticipated, but we finally got Kyle's poop to the right place on the "stool chart".  What a difference this made for Kyle.  Even though he could not verbalize his discomfort before he started Miralax, he sure could talk about how much easier it was to push the poop out once we had the Miralax on-board.  I am convinced that he would not be pooping on the potty today without it.

4) Chart Power II.  After about 4 weeks Kyle was much more comfortable sitting and practicing pushing on the toilet.  His poop was much softer, and he reported easier pooping.  He had even gotten a little bit of poop into the potty on a couple of occasions :).  But he did not want to "push practice" when he really had the urge to poop.  In those instances he was still using a pull-up.  I tried to wait, encourage and reason, but to no avail. 

Then it dawned on me - we need another chart!  I designed a “Kyle's Good Pushing When He has to Poop"  chart.  It had to be formatted a bit differently than our "Push Practice" chart, but utilized the same principles.   I made lots of small steps, most of which he was doing already.  We used more beautiful stickers.  And because what I was asking him to do was so tough and important, I made the reward more enticing - cash for toys.  He still resisted at first, but one day, when I had that chart (already primed with a few stickers!) on the bathroom floor waiting for him, he gave in to my suggestion to "just try".  At first he wanted to finish in the pull-up which I said would be no problem.  More quickly than I expected, he didn't need the pull-up at all.  Kyle was pooping on the potty!!! 

Of course, Kyle is still at a tender place.  We still have a lot of Miralax, laxative/stool records, and sticker charts in our future.  But Kyle has achieved so much that eluded us for so long.  You changed our lives Dr. Tom, and we can't say "Thank You" enough!

 

 


Is it safe to use a stimulant laxative?

A common misconception about stimulant laxatives such as Ex-Lax and Senokot is that chemically-stimulated peristalsis ((intestinal muscle contractions that move stool toward the rectum) will begin to replace natural peristalsis because of damage to the intestinal tissue caused by the long-term use of senna-derived laxatives. However, studies over the past 30 years or more have concluded that the long-term use of stimulant laxatives does not cause intestinal damage. Moreover, published clinical research involving large groups of children treated with stimulant laxatives for a year or longer report that these children did not become dependent on stimulant laxatives to have bowel movements.

Nevertheless, I recommend the following usage guidelines:

  • Use the lowest dose possible.
  • Use intermittently if possible.
  • Discontinue if recipient experiences repeated cramping.
  • Limit continuous use to twelve months.

How do stimulant laxatives (Ex-Lax, Senokot) work?

Stimulant laxatives are used to encourage bowel movements by irritating the inner lining of the intestinal wall. Stimulant laxatives (such as Ex-Lax and Senokot) increase muscle contractions in the large intestine which push stool toward the rectum. These smooth muscle contractions called peristalsis cause the intestine to narrow and then propel the narrow portion forward. Peristalsis looks like an ocean wave travelling slowly through the large intestine.

Unlike water retention laxatives (such as Miralax or Milk of Magnesia) which are used to keep stool consistently moist (soft) and easier to pass, stimulant laxatives are used to increase the feeling of urgency (the need to poop) and to increase the amount of stool produced the following day. It is not uncommon to treat functional constipation/encopresis with a combination of both of these laxatives.

 

 

 

 


Cleanout unnecessary following one poop accident

If a child has just one poop accident during the maintenance phase of encopresis treatment, some parents and pediatricians mistakenly think that the child is constipated again and needs (another) cleanout. Logically, one accident alone, by a child who is on a laxative and has been having regularly large, softer-than-normal bowel movements, is not indicative of a re-occurrence of constipation. Therefore, in this situation, a cleanout is unnecessary.

The correct response in this situation would be to wait and observe what happens in the days that immediately follow the accident. If accidents continue, what is the consistency of the stool? Is it softer or firmer than it has been? If softer, consider decreasing the laxative dose. If firmer, consider increasing the laxative dose. A cleanout should only be considered if the child goes 24-48 hours or more between bowel movements and/or his or her stool turns dark brown in color.


Encopresis, Exercise and COVID-19

Encopresis could be an unfortunate consequence of community efforts to control the spread of COVID-19 due to decreased opportunities for outdoor exercise. Children who are physically active are less likely to become constipated than those who are not. Unfortunately, school closures and stay-at-home orders combined with the closure of parks and playgrounds in some communities severely limit opportunities for physical activity. Forced to stay inside, children will also be spending more time than usual in front of "screens" which we know causes many children to ignore bowel urgency which can lead to constipation.

Parents need to encourage their children to walk, run and ride bikes and scooters etc as much as possible even if it's just up and down the street in front of their home while making sure that they maintain the "6-foot rule". 


Encopresis treatment: 2 frequent mistakes

Parents and even pediatricians frequently make two mistakes when treating children who have encopresis: stopping laxative treatment too soon and treating encopresis as if was normal constipation.

The treatment of encopresis or functional constipation, as evidenced by stool withholding and soiling, typically requires the use of oral and/or rectal laxatives over a long period of time. Stopping laxatives too soon almost always causes withholding and soiling to reoccur.

Normal or occasional constipation the kind that we all experience from time-to-time, is best treated with natural remedies such as eating more high fiber foods, drinking more liquid and getting more physical exercise. Natural remedies are rarely effective for treating encopresis.

On page 5 of "The Ins and Outs of Poop" I list the signs of normal constipation and encopresis with regard to stool frequency (4-5 BMs vs 3 or fewer BMs per week), stool shape and surface ("sausage" with cracks vs sausage/ball/pellet-shaped stools with lumpy surfaces), stool color (dark-to-very dark brown vs dark-to-almost black), hard to push (occasionally vs frequently), uncomfortable or painful to push (occasionally vs frequently), habitual stool withholding (never vs always), soils underwear (never vs often).

 


Withholding bowel movements again following a cleanout

Parents often report surprise and disappointment when their child starts to withhold bowel movements again following a cleanout. This is because they and, sometimes, their pediatrician who recommended the cleanout, do not know the difference between functional constipation (encopresis) and occasional or normal constipation.

Children who have encopresis have developed a "habit" of withholding, which is to automatically contract their anal sphincter to avoid a painful bowel movement whenever they feel bowel urgency. So, because withholding is a learned or habitual response to the feeling of having to poop, it will start again after a cleanout. Step#3 of my Six Step Program is the phase of treatment during which your child's association of pain with urgency is gradually extinguished together with the related habit of withholding.

Children with occasional or normal constipation do not have difficulty passing stool because they are withholding but because their stool has become dry and hard and it is very difficult for them to push out. Normal constipation comes and goes fairly quickly and is usually treated by increasing fiber, liquids and exercise but if continues more than a week or so may require the use of a laxative or even an enema to remove the dry stool in order to prevent the child from starting to withhold.


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”.