The Power of Visible Incentives

 Motivating children to do things like daily practice sits or practicing  pushing can be difficult because of the close association with their (conscious or subconscious) fear of pain when pooping.  For some children, special stickers on their “Good Pooping Chart” are enough of an incentive.  But there are others who need a “stronger” incentive like a bite of candy or a small prize.  

Some parents have found that they can actually increase the “power” of these incentives by making them visible (but out of reach) by putting one or more of them in small plastic sandwich bags taped high up on the bathroom wall. Then, when the child finishes  sitting or pushing, they are immediately given the prize they’ve been admiring.

Real Poop Story: Enemas for a 3 Year Old Boy

Parents rarely talk to each other about their experiences giving their children enemas.  It's understandable, but it's also unfortunate as there is a lot to be learned, especially when considering giving one for the first time.  I asked a parent I have been working with if she'd be willing to write a little about her experiences giving her 3 year old son enemas and she agreed.  Below is her story:

I recently spoke with Dr. Tom and he asked me to write about our experience with enemas. I was initially reluctant to do them. I've never had one myself and giving them to a 3 year old seemed daunting. Prior to using enemas, we went for months using Miralax, trying to come up with a strategy to get him to move toward the potty when he was about to poop.

If his bottom was naked, he would actually run and poop in the potty. But if I put him in underwear, a pull up, or just pants on him, he would poop wherever he was when he felt the urge and none of my strategies got him to budge. So I finally decided to try an enema. I figured that with an enema I could control when and where he would get the urge and so that when it came I could immediately start moving him toward the bathroom.

We talked about it a lot before doing the first one. We practiced in front of the television with a towel to lie on and a pillow. We explained how we would put the "water medicine" in his bottom and then put his pull up back on. We told him that he could keep watching TV until he felt poop trying to come out. But that as soon as he felt poop coming, we wanted him to run into the dining room before he pooped. Up until this point in the conversation, he'd been agreeable or only mildly reluctant about everything, but he flat out said, “No” to the request to go into the dining room before he pooped. I then told him that if he pooped in the dining room he would get a toy car. He brightened up. "Okay!" I consider that moment the turning point in our efforts.

Initially, getting him into position and then accepting the enema took some time. I used the television as immediate positive feedback for getting closer to the right position (he'd get maybe 20-30 seconds of his show for each tiny step in the right direction) and for allowing me to get the enema into him. He pooped in the dining room that morning, in the kitchen the next day and in the bathroom the next morning.

Transitioning to pooping in the potty took a few more days. I eventually figured out that I had to do two things: I had to be in the bathroom when he pooped and I had to make it easy to get the reward he was interested in. So, as soon as we did the enema and put his pull up back on, I went into the bathroom. He was told that he could get one toy for pooping in the bathroom or two toys if he pooped in the potty. He chose the potty!

We used enemas daily for several weeks. Getting him off the enemas was actually harder for us than getting him started. We had to increase his Miralax dosage a lot. He would beg me for "water medicine" and had several accidents during the transition. But as soon we found the right dosage he started pooping in the potty spontaneously.

Unfortunately, after a few months, he started withholding again so we had to restart the Miralax and the enemas. The return to withholding made everyone unhappy, including him. He remembered what it was like to be able to go when he felt the urge and was clearly frustrated. Right now, he gets one toy for pooping with an enema or two for pooping without one. We've recently gotten a couple of spontaneous poops in the potty but most days require an enema. We'd all love to be done with them, but I expect it will happen on his timeframe and no sooner.

Thanks so much to this parent for such a well-written and detailed description. My book also features a chapter on enemas, including other ideas on how to allow your child some control in what can otherwise be an uncomfortable situation.

Incentives can make a big difference

 It is not a coincidence that one of  the longest chapters in my book is the one on the use of incentives. The right incentive, when used correctly can make a big difference in the treatment of encopresis. This is especially true when you ask a child with a history of painful bowel movements to “practice” sitting on the toilet or to “try” to poop on the toilet.

One mother, who had been reluctant to use candy as an incentive, was amazed when her 4 y/o son immediately began to poop on the toilet after she offered to give him "just one" Skittle for every poop.

Equally amazed, was the mother of a 6 y/o girl who began to sit longer on the toilet to poop, only after her mother offered to let her play a game on her iPhone every time she made a “big poop." I’ll talk more about incentives in my next post.

3 y/o Will Only Poop While Standing in a Pull-Up

Many children with encopresis will only poop in a diaper or a pull-up. The longer this continues the more their parents worry that it will become a habit.

Here is what one mom recently said to me:

"My daughter is 3 years old and has been standing to poop with a pull-up on for 3 months now. She is fully potty trained for urine. Would you recommend that I keep trying to get her to poop while sitting on the toilet for a few minutes every day (even if she doesn't push) and only then let her stand to poop in her pull-up? Or, should I wait if she doesn't seem ready? I am concerned that the longer the habit goes on the harder it may be to break?"
Here is my response:

"No need to worry about her developing a habit of standing to poop. She will sit to poop when she is ready. She must first unlearn the habit of withholding. This requires many, many experiences of having a medium to large bowel movement every day, that is softer than normal (e.g. applesauce or pudding consistency) and that does not hurt or cause her discomfort. Unlearning the habit of withholding is a very slow process. The length of time is different for each child, especially for 2 or 3 year olds. You cannot and should not rush her.

While she is unlearning the habit of withholding (in order to avoid an uncomfortable or painful stool even if she has not had such a stool in a very long time!), I suggest that you help her begin to relax on the toilet by making a game of having her sit bare-bottom on the toilet for a minute or two once or twice a day just "for practice" with no expectation of pooping.  This would be in addition to when she sits to urinate.
It helps if she is being reinforced for her bare-bottom practice and urination sits with stars or stickers, etc. Don't force her to practice if she resists now and then. Make it a fun game and encourage her with prizes, e.g. stars and stickers and perhaps an occasional treat for good measure.  Be patient! This is going to take quite a while."

When Should A Child Take Responsibility for Treatment?

A mother I know recently became so exasperated with her 6 y/o daughter’s off and on cooperation with treatment that she told her, “I’m done! You know what you have to do to stop having poop accidents so you take care of it yourself!”

Up until then, this smart, usually compliant but shy first grader always needed to be told to take her laxative, sit on the toilet after meals, listen to her body and not hide her soiled underwear. When she complied she had daily bowel movements and no accidents, sometimes for as long as a month or more. However, when her parents tried to reduce their own involvement, these “good” months would always be followed by a period of two or more days between poops, having accidents and hiding her soiled underwear.

What happened after her mother said, “I’m done!” is amazing. On her own initiative, her daughter now takes her laxative every morning, goes into the bathroom to poop when she feels the urge, and has no accidents. In my experience, this strategy generally does not work with most children (see my post here about the inefficacy of negative approaches) but it’s worth a try with older, independently minded children who generally want to please their parents.

Parents who try this approach cannot use these kinds of statements lightly or often, or their effect is lost. Parents will need to remain committed to what they have said, at least for a period of time that is long enough for the child to recognize the parent's seriousness.  This may mean the child will have accidents again. Remember, it is always okay to change your approach, especially as extended stool withholding can cause real physical harm.  It's also okay to change if your child requests your help again (for example, they have an accident at school and are embarassed).  

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).

Enemas and Suppositories for Encopresis

Even though many of the parents I talk to have never had a rectal laxative themselves, they resist giving them to their children because they erroneously believe that they “hurt”. This is unfortunate because there are many children with encopresis who can and do benefit from them.

With PEG oral laxatives, such as Miralax, the time between administration and defecation is slow and unpredictable. Because there is no standard dose, the unpredictable response makes it difficult to determine the most efficacious dose whether it is for conducting a cleanout or for helping a child have a large, soft bowel movement every day without accidents. If we give too little laxative, the child’s stool remains dry and difficult to pass. If we give too much laxative, the child’s stool becomes almost liquid and may “leak” out.

However, the time between the administration of a rectal laxative and defecation is typically very brief, usually within 1-5 minutes, if not immediate. When given correctly (see Chapter 14 of my book), rectal laxatives will empty approximately ¼ of your child’s large intestine thereby reducing the likelihood of accidents.

Another benefit of an enema or suppository is an increase in the efficacy of rewards used to reinforce pooping on the toilet. In other words, the almost immediate bowel movement on the toilet following a rectal laxative allows for an equally immediate reinforcement for pooping on the toilet. As I explain in my book, the immediate and frequent reinforcement of a new behavior leads to faster learning of that behavior than when reinforcement is delayed or infrequent.

“He Won’t Drink All of His Poop Medicine!”

A problem I hear over and over from parents is that they are unable to get their child to finish all of their PEG laxative. Chapter 13 of my book contains a section titled, “How to get children to drink laxatives.” One suggestion is to mix the powder predissolved in a cold food such as ice cream, yogurt or a smoothie.

Recently, a mother told me about another cold food that works well for her child:

“I have found a way to be certain that my son gets all of his laxative. I have always had trouble making sure he drinks all of the juice I mixed it in. Recently, my mom bought us a Zoku popsicle maker. I make him a popsicle every night with his dose mixed in and he looks forward to it. He eats the entire popsicle, and, therefore, I know he has finished “drinking” all of his poop medicine.”

Popsicles! What a great idea, especially during these warm summer days.  Thanks to this mother for emailing!