Embarking on toilet training with any child can be quite the journey. There’s the “regular” toilet training questions we all wonder (When should I start? Is my child ready? What rewards should I choose?), but for parents of a child with additional needs, introducing the concept of transitioning out of nappies can be a significant challenge.
Toilet training requires a huge shift in your child’s awareness and routine. All of a sudden, your child needs to pause his/her current activity to “have a try” on the potty or toilet. Constantly pulling down undies and pants can put your child’s sensory thresholds to the test, and even remembering the sequence of the toileting steps can be overwhelming.
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Once you’re in the thick of toilet training, you may notice your child is a little constipated. Your child may have skipped a few days of passing a bowel movement and feel a little lethargic. More often than not, this is just regular old constipation. We smuggle some prune juice in our child’s milkshake and then it’s back to normal.
Did you know, however, that there is a more complex issue that presents like regular constipation but requires a completely different treatment approach?
Think of your biggest fear
What’s your biggest fear? Let’s say it’s a fear of snakes. Would you like to talk about snakes with others? Surely not. Would you like to camp in a snake-infested bush area? No way. If your friends were going to a snake and reptile show, would you go or make up an excuse to avoid it? What if you were told you HAD to hold a snake after dinner every single day? If you’re like me, you would start to feel agitated, scared, and even experience physical symptoms like a racing heart and sweating.
Stool withholding defined
For some children, both typically developing and those with additional needs, pushing out a bowel motion is like facing their biggest fear. Every. Single. Day. What do these poor children do when they feel a poo is on the way? They react the same way adults do when faced with their biggest fear—they try to avoid it.
This leads us to the term stool withholding. Simply defined, stool withholding refers to holding in a bowel motion instead of passing it out of the body (Ferguson, 2015). If done for long enough, stool withholding removes the “urge” to poop. The child then feels short term relief that he/she has avoided his/her fear. He/She then repeats this action the next time he/she feels the urge to poop. This vicious cycle then causes a build-up of old, hard stool in the colon, which then presents like constipation.
Why did my child start stool withholding?
It is hard to identify the exact “Day Zero” for the onset of stool withholding. For some children with additional needs, stool withholding may be influenced by underlying conditions relating to developmental delays, sensory challenges, or language disorders.
According to Ferguson, (2015) there are three additional main trigger points that may cause the onset of stool withholding:
- A painful experience pushing out a bowel motion—quite possibly from a case of garden variety constipation!
- The commencement of a new childcare or education environment, such as commencing day-care or kindergarten
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Signs your child might be stool withholding
Whilst every child is different, there are some subtle signs your little one may be experiencing fear about pushing out a bowel motion:
- Fear of using the toilet or potty
- Hiding when asked to use the toilet or potty
- Soiled undies, either small stains or whole bowel motions
- An increase in wee accidents, as the full colon is pressing on the bladder
- Physical signs such as stiffening the body, crossing legs, or turning red-faced in attempts to hold in poop
How do you treat stool withholding?
Unlike regular constipation, which is purely about managing the physical symptoms, stool withholding requires tackling the underlying emotional issues. On a physical level, your GP or pediatrician can provide education around administering laxatives for your child. This will help keep the stools soft, making them easier to pass.
Addressing the fear—how a social story can help
Social stories are a wonderful resource for children with autism. Simply defined, a social story is a created story that outlines the expectations and steps involved in completing a particular task or skill. Social stories can help prepare your child for a task or activity, outline his/her expectations in the scenario, and help him/her see the individual steps involved.
Four tips for a successful social story:
1. Give your child a personalised social story
The more personalised a social story is, the more your child will identify with it. Add specific details related to your individual child—his/her name, who he/she lives with, what he/she enjoys doing. This will help your child attach meaning to the story and take on the routine and strategies.
2. Use clear, positive language in the social story
Social stories should outline the best case scenario for the task or situation. Rather than using negative language like “I do not…” or “I will not…,” flip this around into a positive sentence—e.g., ”I can pause my game to sit on the potty for three minutes. I can play on Mum’s phone when I sit on the potty.”
3. Target your social story to a specific behavior
The road out of stool withholding can be lengthy. As much as we want our children to use the toilet, this may be a long term goal for them. Going back a step and starting with simply pushing OUT a poo (into a nappy or into the potty) may be more achievable for your child. Once your child has conquered this skill, create an updated social story to support your child through the next step—progressing to the toilet.
4. Make the rewards clear in the social story
Find your child’s internal motivator—is it that new box of Lego? A pretty barbie doll? Include the reward into the social story and explain what your child has to do to get it. For example, it might be “If I sit on the potty for three minutes, I get 10 minutes of iPad time.” This helps your child to see exactly what he/she needs to do to get the reward and can help to maintain his/her motivation and engagement.
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Stool withholding in children is a confusing, silent condition that can be extremely challenging for families to navigate. The good news is there can be light at the end of the tunnel, and with the right resources, we can help support our little ones to help them feel calm, stay safe, and ultimately thrive.
Link to Stool Withholding Social Story: https://mailchi.mp/1179cddedffa/socialstory-stoolwithholding
References: Ferguson, Sophia J. (2015). Stool withholding. What to do when your child won’t poo! London: Macnaughtan Books
This article was featured in Issue 116 – Enhancing Communication Skills