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.

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.

Parents of children with functional constipation often report that their child will urinate in the toilet with no problem but will only defecate if they are wearing underwear or are in a diaper or Pull-up. Why is this? Understandably, parents think that if their child is relaxed enough to pee in the toilet he or she should also be relaxed enough to poop in the toilet. However, as I explain in the 2nd edition my book The Ins and Outs of Poop: A Guide to Treating Childhood Constipation, the fear that underlies functional constipation is related to relaxing the anal sphincter (not the urinary sphincter!) whenever a child consciously or subconsciously feels the need to poop. Most of the children who pee in the toilet but do not poop in the toilet are still actively withholding and frequently have poop "accidents" in their underwear or diapers (See Chapter 9). In my book I explain why withholding must be treated and stopped before the application of "successive approximation" behavioral strategies can enable these children to poop on the toilet without fear ( See Chapter 16).

Our doctor says my 5-year old can't be constipated because he poops every day! But he has frequent "poop accidents."  Any ideas?

This is a very common misconception about constipation even among pediatric healthcare professionals. The fact is that a child can have a fairly large, soft stool every day and still be constipated.

In my book, I talk in more detail about the two types of withholding: complete and incomplete. With incomplete withholding a child may go to the bathroom every day but still not fully evacuate his or her rectum. Over time, this results in a gradual backup of stool which slowly, but surely, stretches the rectum to the point where a child begins to have stool accidents.

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:

"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.

The Squatty Potty is a footstool for children and adults which elevates your feet while sitting on the toilet. The footstool changes your posture so as to more closely approximate squatting than sitting. It comes in both 7" and 9" tall versions.

Squatting is thought by many GI doctors to be the most natural and efficacious position for defecation. I agree. In the squat position, the angle between the rectum and the anal canal is wider/straighter than it is in the sitting position thus allowing stool to pass through with less effort/straining.

How does this relate to functional constipation/encopresis)?

In my book, The Ins and Outs of Poop, I talk about how one or more uncomfortable or painful bowel movements can cause a child to begin to withhold stool whenever she or he feels urgency so as to avoid another uncomfortable or painful bowel movement. Unfortunately, withholding can become a conditioned or habitual response to the feeling of urgency which almost inevitably leads to functional constipation aka encopresis. 

The key to preventing functional constipation is to act quickly with natural remedies when your child has occasional constipation in order to keep his or her stool soft and the need for pushing/straining at a minimum.

In my opinion, the use of a higher than normal footstool such as a Squatty Potty should be thought of as one of the natural remedies for occasional constipation along with more common remedies such as increased fiber and exercise. Footstools like the Squatty Potty may also be of help in the long-term treatment of encopresis.

I recently received a request for a telephone consultation from the mother of a 13 year old girl who had been withholding her poop for eleven years. She said that her doctors had recommended Miralax, ultra sounds, x-rays, therapy and even a barium enema when her daughter was only 4 years old, which, she said, "was horrible beyond belief and probably made everything worse".

Because she had not yet read my book, I suggested that she do so before we talked by phone. Shortly thereafter she sent me the following email:

Dear Dr. Tom,

Just to let you know that my 13-year old daughter wept like I haven't seen her weep as we read your book together and we read about kids who were like her, who are great achievers and great kids, but who have greatly struggled with functional constipation. When she read that a girl had actually recovered, she just started sobbing. There it was, a possibility she had never heard of... she has felt so alone. We all have because most people aren't willing to talk about this, so, we haven't known that this was a problem others were facing.

There has been so much shame. Doctors have mostly just sent us away telling us to feed her more prunes or giving us sheets on normal constipation which we knew somehow was very different. There has been much trauma and loss of trust with the medical world over the fact that doctors couldn't hear us, for example, when we told them that she was able to hold in an enema for 13 minutes as a four year old.

It has been a week and we are all supporting my daughter in going to the bathroom every day with Miralax.  We are going to continue for 6 months with her going every day and see how this goes and contact you again if we need guidance along the way.