Dr. Greene, my four-year-old son has a history of withholding bowel movements. He’s trained for urine just fine but refuses to poop in the potty or toilet unless under extreme duress, and after a few weeks of trying, we’ve given him his diapers back. He’s now happy to poop every day, hence avoiding the anal fissure problem, but what keeps kids from pooping in the potty? Being four and in Jr. Kindergarten, this is a concern for us.
Dr. Greene’s Answer:
One of our advantages as parents is our size. If we need to get our preschoolers into our cars in a hurry, and friendly negotiations have failed, we can still scoop them up and slide them in. If two preschoolers are fighting, we are big enough to gently but decisively separate them.
But in the arena of helping kids to poop on the potty, our superior size affords no advantage. We can teach them how to do it, we can tell them when to do it, but we can’t just make them do it. They are able to simply decline. The longer they refuse to comply, the more frustrating and embarrassing it becomes for us as parents (especially if there is peer, or in-law, or school pressure!).
We hear that if we just wait, they will learn. We’re told that no one graduates from high school in diapers. But we wait, and there is no progress.
We throw our efforts into getting them to use the potty, sometimes to the point of “extreme duress,” but that tack doesn’t work either. The more we try to force them to use the potty, the more they can resist. And they will win.
Children don’t have to poop on the potty unless they want to.
The good news is — they want to!
Children have a deep, urgent desire for growth and mastery. They would love to be able to poop on the toilet like their parents, like their teachers, like their friends. This longing is profound, and will win out in the end.
What could be powerful enough to block this freight train of progress?
There are several answers to this question, but in your son’s situation it sounds as if he is trapped in what I call the D3 cycle (discomfort – dread – delay).
Children can enter the D3 cycle at any point. Sometimes it begins with an uncomfortable experience passing a hard stool created by a change in diet or a brief illness. Sometimes the starting point is simply the fear of sitting over the gaping hole in the potty to poop. Sometimes children are engaged in playing and choose to ignore the urge to poop, holding the stool in just to delay interrupting a vitally important game.
Whatever the starting point, they end up having a painful experience. When the next urge arrives, the child decides to delay pooping in order to avert what happened last time. The longer he delays, the firmer the next stool becomes. When he finally does poop, the event is even more uncomfortable — confirming his fears. What he dreaded was true!
He vividly learns from this experiment, but it’s the wrong lesson. So next time he is even more determined to hold the stool in. Discomfort leads to dread; dread leads to delay; delay leads to discomfort. The rectum stretches internally so that more stool can be held, and soon urges to defecate are not often felt. The D3 cycle becomes a powerful trap. Progress is derailed.
The D3 cycle must be broken before moving ahead with potty learning.
Sometimes going back to the “good old days” of using a diaper can break the D3 cycle. The child relaxes, the stools get soft, and the tension disappears. Stools again come regularly and without protest. It sounds as if this has happened already for your son. This solution runs the risk, though, of forming a very strong connection in his brain: diapers are good, potties are bad!
Sometimes modifying the diet can result in soft enough stools to break the D3 cycle. I’ve given dietary suggestions for this elsewhere.
In some children, the D3 cycle is so entrenched that in order to break free they need a stool softener to take the process out of their control. This is especially common if the stools have been hard enough to produce anal fissures. One excellent way to soften the stools is with Miralax. Miralax is a powder, mixed into a glass of liquid, that helps increase the water content of stool, thus reducing constipation. It works best if you also increase the amount of liquid your child drinks each day. Talk to your pediatrician for information on the best way to dose Miralax for your child.
If the child does not begin having soft stools daily, increase the dose a bit until you reach a dose that works. (Don’t go above 3 times the starting dose without checking with a physician.) You may need to adjust the dose downward if the stools get too loose or too frequent.
Once you’ve arrived at a dose that works, keep him on this dose for about 2 weeks. This will give time to break the connection in the child’s brain between poop and pain. Children relearn that stools don’t hurt. Also, the rectum shrinks back to normal size, fissures heal, and (perhaps most importantly) the urge to poop is once again felt.
After two weeks, gradually taper the Miralax over another two weeks or so. This process will often break the D3 cycle completely.
We also know that increasing dietary fiber and increasing liquid intake help make softer stools. But for the majority of children, adding fresh fruits and vegetables to their diet is quite a chore! Other alternatives include Benefiber (a fiber supplement). Benefiber is one of a few fiber supplements that are tasteless powders and can be sprinkled on your child’s favorite foods. Once the D3 cycle has been broken, it’s time to revisit the issue of pooping on the potty.
Often the quickest way to success is to make steady, little steps forward, rather than just trying again to get him to go straight from diapers back to the fearsome potty.
First, encourage him to do his pooping in the bathroom — like you. He can keep his diaper on, he can be across the room from the potty, but he’s in the right room. Usually this step isn’t too tough. If it is, figure out why (difficulty getting cooperation in many areas, difficulty breaking away from play, defiance, etc.) and address the underlying issue. Once he has comfortably pooped in the right room for 3 days or more, he can take another little step when he seems ready.
Next, have him poop sitting down — like you. He can sit on the floor, on the potty with the lid down, on the potty with the lid up, or wherever he wants in the room. He still gets his diaper (or pull-up or underpants as the case may be). Again, once sitting has become comfortable, he can try another little step.
If he has been sitting on the floor, he moves to the potty or toilet. If the lid has been down on the potty or toilet, now lift the lid. He still gets to wear the diaper (or whatever). This step is usually surprisingly easy. Wait until he is comfortable with each stage before he takes another tiny step.
The next step may be to simply remove the diaper and have him go on the potty — like you. Many kids will move from the last level to this one with unexpected ease. If you gauge that this will not be the case for your son, you can instead cut a little hole in the bottom of the diaper. He can go as before, and the poop may or may not fall into the potty. As the days go by, make the hole larger and larger. I’ve known some kids who just wore a waistband for a bit! Before long, he will want to be free of the diaper altogether, now that he is free from the fear.
Your son wants to use the potty even more than you want for him to –he just doesn’t know it yet. His practical experiments have proven to him his hypothesis that this achievement is unattainable for him. He is discouraged and afraid, and doesn’t want to have to face pain, failure, and fear.
By loosening him from the chains of the D3 cycle, and then by taking this huge task that had inspired dread, breaking it down into small achievable steps, and getting him going again, you can set him free to enjoy the growth he is longing for.
And you also model for him an important process. This approach is a potent tool whenever he (or you) gets trapped in the eddies and bywaters of development. It will serve both of you well whenever an overwhelming obstacle (whether it be a term paper, or making the baseball team, or weight loss, or credit card debt) looms large on the path ahead.
I hope he has a wonderful junior kindergarten year!