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 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.

A parent recently asked me if soiling at home but not at school and frequent daytime wetting might be related to "painful constipation":

Question: My daughter had some painful constipation several months back which seemed to be the beginning of her soiling issues. After that time she started soiling frequently, as many as 4 or 5 times a day. She is soiling less now but there are two questions I have about the soiling. The first is that she rarely soils at daycare, she typically only soils at home. The second is that she is now wetting her pants frequently, something she didn't do when she started soiling. I think that all of her soiling issues point back to those constipation issues but I don't know if these two behaviors are in line with that idea.

Answer: Painful bowel movements will often lead to withholding followed by soiling (encopresis). Since your daughter continues to soil, albeit less than at first, she is still constipated.That she tends not to soil at school is also typical in the early stages of functional constipation. Ongoing withholding and soiling are often associated with day and night wetting. This is because a distended or stretched rectum will press on the bladder causing occasional leaking during the day and/or bedwetting at night. This is all covered in my book.

A mother recently reported to me that: “When we were first training our 4 year old son, he had a difficult bowel movement on the toilet. He cried and became very upset. That was when our worst problems began. After that, he didn’t want to poop at all. He became constipated and would only poop at night in his pull-up, after he went to sleep.”

Having bowel movements in bed, while falling asleep or while sleeping, is not uncommon for children who are functionally constipated.  It usually occurs at the onset of functional constipation when a child is intentionally withholding poop in order to avoid another painful bowel movement. Intentional withholding requires a child to pay close attention for any bodily signals of urgency. However, once the child falls asleep, conscious withholding stops and stool passes.

Compared to other symptoms of functional constipation, nighttime bowel movements are relatively easy to eliminate once a child begins to withhold less (or not at all) during the day. Detailed instructions for decreasing and stopping withholding can be found in The Ins and Outs of Poop.

I have received requests to post useful poop-related products. Though the marketplace and brands are always changing,  I have been recommending certain types of products to my patients for years. The ones I will post are my current favorites.  Most are available on Amazon.com and in major stores such as Walmart, Target, Babysrus or Toysrus. 

Dr. Tom's Recommendation: Children's Potty
BABYBJÖRN Potty Chair

For children new to the potty or during potty training, I like the BABYBJÖRN Potty Chair shown above.  This version has a high back which provides a sense of security when teaching children to sit back and relax.  The high back and arms allow children to easily, slowly and carefully seat themselves. The high "splash" guard at the front of the interior bucket protects the floor and is especially useful with boys.  This seat comes in many different colors.

The email below, written by a real mom with her permission (names changed for privacy), is a follow-up to the Real Poop Story in last month's email newsletter (sign up at left) which featured her original email to me regarding her 6 year old son who would only poop in a pull-up, read it here.  I am very impressed with this mom: her willingness to try incremental steps regardless of how long they take and how she quickly learned to "read" her son and customize the steps and materials to suit him.

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!

This month's Real Poop Story comes from a parent who requested a phone consultation with Dr. Tom.  Dr. Tom requests that parents email him a brief summary of their child's poop problem prior to their initial phone consultation. He also answers post-phone consultation questions by email and encourages parents to update him periodically about their child's progress. Here is one mother's initial email reprinted with her permission and with names changed for privacy.

Hi Dr. Tom,