The Potty Boot Camp

This article by Lisa Jo Rudy is helpful for parents of autistic children. Potty training kids with autism can be challenging at times, and this article reviews some of those challenges and specifically addresses fear of pooping in the potty.

The author discusses reasons behind why the child might be reluctant and/or difficult to train, including sensory deficiencies, no interest in what their peers are doing, and no interest in ‘big boy (or girl) underwear.’

To read the full article:
Toilet Training a Six Year Old with Autism: Your Advice Requested

Ask Lisa - Free Pediatric Advice: Withholding Stool

I’d love to take credit for this advice, but it was written by Lisa-Ann Kelly R.N., .N.P.,C.Certified Pediatric Nurse Practitioner.

In her article, Lisa-Ann presents a very thorough discussion behind encopresis, or chronic constipation and the medical management of the condition. My favorite tidbits of advice from her article are:

1. Feet Positioning: When your child is sitting on the toilet, place a stool under their feet so their knees are high. This helps the BM physically move more easily.

2. Laxatives: When resorting to putting a child on laxatives, keep them on them for THREE to SIX months. It might take this long for the child to forget that it hurts to poop. Any child on laxatives for any length of time MUST be monitored by a medical professional.

3. Warm baths and Vaseline: Place your child in a warm bath, water high up over the belly, a FEW times a day until the stool passes. The second the child gets out of the water, place Vaseline around the rectum so the poop can slip out more easily. The Vaseline also makes the child less able to hold it in.

Original Article Text:

Withholding Stool

Lisa,

I have a four year old who is having problems going doodoo. What she will do is hold it for days, she will get down on her knees and almost struggle not to go. She usually ends up going in her pants, just a little bit then when I put her on the toilet she sits and holds it in again yelling about how she does not have to go. When she finally does go it takes her quite a bit of work. The worst of it is the size of it. It has got to be so painful for her, my daycare lady actually has to break it up before she can flush. Here at home it is the same way, so big in diameter that it will not go down the pipe. How can such a huge doodoo come from such a little girl?? I have tried everything from greens to grapes, even stool softeners. Is there anything you can suggest that may help her out?

“Desperate for Daughter to Doodoo”

Dear “Desperate for Daughter to Doodoo”,

Stool withholding or Encopresis is a condition that occurs in children who do not defecate when they need to. Instead they hold in the stool, the longer the stool is held in, the more water that is absorbed from the stool into the body. This results in a hard, large stool. The longer the child holds in the stool, the harder and larger the stool becomes. The colon and rectal vault accommodate the large stool by stretching and expanding, which allows the stool to become larger and thus a vicious cycle begins. The larger the stool, the more painful it is to defecate and because it is painful the child holds the stool in longer. Sometime the child holds the stool in so long or the stool becomes so hard that diarrhea or loose stool seeps around the blockage and children end up soiling themselves.

Usually children develop stool withholding or Encopresis because they had a past experience passing a hard stool due to constipation. They remember the bad experience and fear that stooling will hurt again, so they hold in the stool to avoid the pain. (1) The child does not realize that holding in the stool makes the situation worse because they are too young to understand cause and effect. When a parent sees a child holding in stool and in distress, it is quite upsetting and as a result psychological effects worsen the situation.

There is a thought that there may be a genetic predisposition to stool withholding. It is believed that children with Encopresis absorb more water from their stool in the large intestine leading to hard stools which are painful to pass. This is an explanation why many children with stool withholding have a history of constipation since infancy.

The first step in treating Encopresis is to evacuate or clean out the colon. (1) The large stool that distends the lower colon needs to be removed so that the colon can shrink down to its normal size. The best way to evacuate a colon is with a Pediatric Fleets enema, but this procedure is invasive and may be very stressful and only add to the psychological effects of stool withholding.(1) Therefore many Doctors and Nurse Practitioners will attempt evacuating the stool with alternative methods. I prefer to have a child sit in a warm bath, with the water high up over the belly a couple of times per day until the stool is expelled. The minute a child gets out of the bath, I suggest liberally applying Vaseline to the rectal area so that the stool can slip out easier and the child will not be able to hold it in. I recommend telling your daughter that the Vaseline is special medicine to help her go doodoo. Most children believe this and it helps them go. It is also a good idea to put Vaseline around the rectal area each time the child sits on the toilet to have a bowel movement.

The next step is to set up scheduled times for your child to sit on the toilet. Specific time sitting on the toilet should be incorporated into your daughter’s daily routine. Instead of asking your child to sit on the toilet when she feels the need to go, choose periods during the day where the child must sit for 3 to 5 minutes everyday regardless if they need to go or not. First of all, scheduled times to sit on the toilet eliminates the need to coax or battle over toileting. Secondly, if you wait for a child to tell you when she needs to go, she will tell you that she doesn’t need to go when she really does because she is afraid that it will hurt. Also, a child may not sense the need to defecate because her rectum is so distended she may not feel the sensation the way that a child without a distended colon feels it. The best time to schedule time sitting on the toilet is after meals and in the morning because this is when the colonic motor activity is the highest. (1) Putting a stool under your daughter’s feet when she is sitting on the toilet may help. Proper foot positioning while defecating can help her push the bowel movement out. (2)

In addition to evacuation by using enemas or baths, colonic evacuation can be done with the use of laxatives. Although you said that you already used laxatives, laxatives alone usually do not work. A combination of all therapies together tends to be more successful. Sometimes the type of laxative used or amount given needs to be adjusted. This can be managed best with the assistance of your daughter’s Doctor or Nurse Practitioner.

Mineral oil works many times if given in the correct amount. One tablespoon of Mineral oil blended in the blender with your daughter’s favorite juice twice per day is a good start. Senna products have also been very successful for many children. If you have tried many over the counter products with no success, you can discuss with your Doctor or Nurse Practitioner the option of giving Miralax. Miralax is a prescription medication which is very successful in treating children with constipation and stool withholding.

The important thing to remember about giving laxatives is that they have to be used regularly. The laxative should be used on a daily basis until the stools are a soft consistency and no longer painful to pass. It’s important to continue the laxative until stooling is no longer feared by the child and they forget that going to the bathroom hurts. Some children need to stay on the medication for 3 to 6 months in combination with other therapies before they can be weaned from it. Some parents are under the impression that the medication doesn’t work because after giving the medication a few times they discontinue it and the stool returns back to the hard painful stools that they were before the introduction of the treatment. If the medication is given intermittently, the hard stools return, the child has a bad experience stooling and the cycle begins again.

In order to maintain soft stools once they are obtained, diet and exercise also needs to be addressed. Although you already tried grapes and grains, it is also important to increase your daughter’s fluid intake and avoid foods that tend to be binding. In some children, soy, rice and bananas cause hard stools and may need to be limited or removed from the diet to prevent constipation. Increasing the amount of foods that promote stooling such as peach nectar, prune juice, frosted mini wheats and oatmeal also helps. Exercise increases peristalsis, or the movement of the intestines and helps a child move her bowels. It is important to make sure that your daughter has exercise daily.

A child on a laxative should be monitored regularly by a health care professional in odor to watch for fluid and electrolyte imbalances and improper absorption of nutrients. In addition, a healthcare professional needs to monitor your child’s care to rule out other health conditions that may cause or contribute to hard stools. A child that has no response to therapy or persistent problems many times will have testing done to rule out other conditions that cause constipation. These conditions may include Hypothyroidism, Cystic Fibrosis, Celiac’s disease, electrolyte imbalances, Diabetes, lead toxicity, internal or external anal lesions or Hirschprung’s disease. Although in most cases, constipation is due to diet and inadequate stooling practices a further investigation may be warranted if symptoms persist. In some cases a child with persistent problems with constipation or stool withholding is referred to a Gastrointestinal Specialist for a further work up and treatment.

If your child has a distended abdomen, fever, vomiting, loss of appetite or increasing abdominal pain associated with constipation or stooling it would be important to have her evaluated right away to rule out an intestinal obstruction or other complications of constipation.

(1) Chronic Constipation in Children: Rational Management. Consultant for Pediatricians. 2003; April:152-155.(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. W.B. 2nd ed. Philadelphia, PA:Saunders Company. 1994: 1044.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

(This blog post is intended to supplement my original article/post entitled “Help! My Toddler Won’t Poop on the Potty!”)

I hear from parents over and over again about their child refusing to use the potty to poop. These kids inevitably are doing great with their pee training, but will absolutely NOT poop in the toilet. Some kids just go in their underwear while others actually run and hide. In my book, “The Potty Boot Camp: Basic Training for Toddlers” I dedicated a full chapter (The ‘Potty Poop Camp’) on the topic since it is such a common occurrence!

One of the most common reasons for a child’s refusal to use the toilet for ‘#2′ is fear. Some are afraid of the sound of the ‘plop’ or the feeling of the air hitting their bottom. The most common cause of fear, however, is that the child has has a previously painful bowel movement.

That’s why I am excited about this book by Howard Bennett, M.D. The book, entitled, “It Hurts When I Poop: A Story for Children Who Are Scared to Use the Potty” It tells a story about a little boy named Ryan who is afraid to use the toilet. Through the book, children follow along with Ryan’s “poop program” as he learns to overcome his fears.

Every review I have read about this book is a positive one. Below are a few comments from parents who had positive results from reading the book to their child:

• “When you have been through 2 years of poop problems, and not knowing what else to do, this book is the answer. It describes perfectly how my daughter felt, it was if she wrote it. I love this book, it is her favorite book. Some tomes we don’t talk about these kind of this because we are ashamed, but now with this book it is easy to help in this matter. I am so thankful I found this book, I LOVE IT!!!!!!!!!!!! “
• “My daughter has had a poo poo problem for three years and FINALLY!!!!…..I purchased the book and from the first time I read it to her she started to relate to Ryan. She wanted me to read her the book at least five times a night and when she was on the toilet. People don’t understand the late nights crying on the toilet for three hours at a time unless they have been through something like this. My daughter was in pain every day and Ryan has the exact symptoms as my daughter had. I really wanted to thank the author of this book. I also purchased one for my daughters doctor. If your child has this problem please buy this book it really has done wonders for my daughter and the family. “
• “After months of abdominal pain, I was desperate for my son to find some sort of solution to his….err….ummm….going problem. He wouldn’t poop. No matter what he would not poop. Enemas, laxatives, fruit, it was all like trying to shave your head with a butter knife….. FUTILE I bought this book at Barnes and Noble (sorry amazon) on a whim. Without even reading it, my son was pooping himself right in the store! It was like he knew what was coming so he readied his bowels. When we got home I sat him on the toilet and read him the story. 5 months of impacted fecal matter came pouring out of him like water from a fountain! Oh we are so lucky to have found this book. Without it my son would probably have blown up like that blueberry girl from willy wonka. Yay Poop!”

In my book I discuss the topic of fear - and that every parent needs to address this issue first before they will ever get cooperation from their child. I think this is a great first step to take when you are constantly cleaning up poop!

Once the fear is gone, other issues can be tackled. Some children are just plain stubborn! When that’s the case, it’s on to “Potty Poop Camp!”………..

I’ve always been a fan or Dr. John Rosemond. His toilet-training techniques are straight-forward, no-nonsense, and just plain make sense to me. In this article, he discusses a method that parents can try when their toddler is refusing to poop on the potty. I think the advice makes sense - even though many parents might comment that the method seems “harsh.” I think we should all note that the mother of the child in the article says, “No crying, screaming, nothing. My husband and I have battled this issue for many months now, cried, and lost sleep over it. I’m sitting here absolutely astounded at how simple it has been. Unless told otherwise, we’ll continue to use this method until we see him initiate the trip to the bathroom himself.” It hardly seems as if the child was traumatized by the event. I’ll be planning on adding this technique to the chapter of “The Potty Boot Camp” that discusses the pooping issue. It is just one more thing a parent can include in their arsenal of methods to try when they are dealing with poop everywhere but in the potty!

Here is the article text:

Try this simple tactic to get past toilet-training impasse
John Rosemond

One of the consequences of postponing toilet training until well past the second birthday (per the bad advice of most post-1960s parenting “experts”) is a well-documented problem known as “stool refusal”-children three and older who will use the toilet for urinating but stubbornly refuse to use it for a bowel movement. Fifty years ago, when most children were expected (and expected they were!) to use the toilet successfully before they turned two, this problem was rare; today, it is almost commonplace. As one might imagine, it is one of the most frustrating of all parenting problems.

And so it recently was for the parents of a three-and-one-half-year-old stool refusing boy. The parents had talked and rewarded and punished and talked some more, all to no avail. In the meantime, they were beginning to suffer self-induced baldness. Several web-based experts weighed in, saying that stool refusal almost certainly indicates deep-seated psychological issues, implying that the road to solution would be long and longer still.

Over the past several years, a colleague and I have developed a program that has been very successful at persuading these kids that it is in their best interests to-to use contemporary vernacular-”give it up” for the potty. This child was the perfect candidate. I recommended that immediately after breakfast on the morning of P-Day, the parents take this recalcitrant child to the bathroom, remove his clothes, and say, “We spoke to your doctor, and he said you have to stay in the bathroom, without any clothes on, until you have a poopy. When you have a poopy, call us to see, and then you can put on your clothes and play. Call us!” I told the parents to keep it short and simple and then cheerfully turn and walk away. If their son refused to stay in the bathroom, they were to gate him in, again explaining that such were the doctor’s orders. When he produced a bowel movement, they were not to make a big fuss or reward him, but simply acknowledge his success in a low-key manner.

To the parents’ amazement, their son had a bowel movement after five minutes in the bathroom on B-Day. They asked, “Now what?” to which I told them to stay the course. He took three minutes on day two. His mother wrote: “No crying, screaming, nothing. My husband and I have battled this issue for many months now, cried, and lost sleep over it. I’m sitting here absolutely astounded at how simple it has been. Unless told otherwise, we’ll continue to use this method until we see him initiate the trip to the bathroom himself.”

One week later, she gave me a second update: “As we bring tonight to a close, it marks a full week since we put into action your plan. We have had ZERO accidents this week. We left the gate up for a few days just as a reminder but it’s now gone completely, and he is going to the potty on his own. He has been an absolute joy to be around since not having to fight the potty battle.”

There was no trick to this at all. The solution involved nothing more than clearly stated expectations and a clearly defined boundary. In short, the parents stopped wishing (in the form of pleading, explaining, rewarding, and exploding) their son would poop in the potty and told him he was going to. Conjuring the doctor’s authority simply reduced any possibility of rebellion.

Before closing this column, I would be remiss not to note that on occasion, stool refusal is actually constipation or the result of some other physical problem. Before coming to me for advice, the parents checked this possibility out with a physician. Any parent thinking of trying this should first do the same.

*About the Author: John Rosemond has written nine best-selling parenting books and is one of America’s busiest and most popular speakers, known for his sound advice, humor and easy, relaxed, engaging style. In the past few years, John has appeared on numerous national television programs including 20/20, Good Morning America, The View, Bill Maher’s Politically Incorrect, Public Eye, The Today Show, CNN, and CBS Later Today.

Click here to visit Rosemond’s Web site, www.rosemond.com.

Suzanne Riffel, author of “The Potty Boot Camp: Basic Training for Toddlers” - a potty training program that combines the best of the best methods. Visit www.ThePottyBootCamp.com for more information.

***Note***
“The Potty Boot Camp: Basic Training for Toddlers” now includes a chapter about how to get your toddler to poop on the potty. It’s straightforward and step-by-step. Please contact me at suzanne@thepottybootcamp.com with any questions you might have.

A question that I am asked on a regular basis is “Why won’t my child poop on the potty?” Know that you are not alone if currently facing this common toilet training problem. As frustrating as it might be, steps can certainly be taken to overcome this stumbling block to diaper freedom.

More common in older potty training children (2.5 years and older), the “poop” issue can become a major power struggle between you and your toddler. The reasons for this apparent stubbornness can be caused by fear, medical problems, embarrassment, or standard toddler contrariness. Let’s tackle each issue one by one:

Medical Problems:
First, a disclaimer: If you believe your child’s unwillingness to poop on the potty is truly a medical issue, please consult with your pediatrician. There is a condition called encopresis which is caused from chronic constipation. Children experiencing encopresis have a problem with the bowel that dulls the normal senses about the urge to go. A more benign medical condition is basic constipation, in which the child fails to have a bowel movement over a couple of days. Usually an increase in dietary fiber or a mild stool softener will help to relieve the situation.

Fear:
Believe it or not, many children believe that poop is a part of their body. Imagine how reluctant you might be to use the toilet if you thought a body part might fall off each time! For other children, the fear comes from the actual sensation of air hitting their bottom, the “plop” that can be heard in the water below, or the sound of flushing. Other children have had a previous painful episode of constipation and they become afraid to experience it again.

Embarrassment:
I think many of us can confess to occasionally “making a stink” about our child’s poop. We joke or tease about the smell, or the size, or the consistency of the poop. Some children, especially the “sensitive” ones, can become self-conscious about this bodily function. If you think this might be the reason for your child’s problem, try to discuss poop in a very matter-of-fact manner. Make it clear to your child that pooping is a very normal and natural part of life. It might be helpful to read books to your child such as “Everyone Poops” by Taro Gomi.

Stubbornness:
For most parents reading this article, the “terrible twos (or threes, or fours)” might be the culprit in your potty problems. The key in convincing your child to use the toilet rather than their pants is to find a method to make the child finally decide that life is just easier and more sanitary if they use the toilet. Some parents are violently opposed to bribes or “punishment” but sometimes the basic concept of “you get as good as you give” is the magic answer. If your child cooperates, they get positive reinforcement. If they don’t, negative reinforcement is dispensed. Allowing the child to decide if the positives outweigh the negatives will actually empower them and allow for increased independence. It’s also temporary - believe me, you won’t have to bribe your child to poop in the potty on the day of their high school graduation!

“The Potty Boot Camp: Basic Training for Toddlers” is a step-by-step toilet training manual that will have your toddler diaper and accident free in about a week. For more information, please visit www.thepottybootcamp.com.