Stool withholding: How to stop your child from withholding stool
Toilet training can be an enjoyable experience given that everything goes as planned. As parents, we all know that it rarely happens.
There are several hurdles in the toilet training journey, one of the major ones is stool withholding.
Often parents assume that the child is simply adamant and continue to plead, bribe or punish them to get the job done.
Stool withholding is a behavioral problem that can be solved properly without much pain and anxiety for both parents and the child when understood properly.
What is stool withholding?
‘Stool with-holding’ is a voluntary refusal to pass stools even when there is a strong urge for defecation usually in a child who is old enough to understand toileting requirements.
It can usually begin as ‘stool refusal’ which is when the child refuses to use a potty chair or the toilet to pass stools while comfortably using the same for passing urine.
This initial refusal to use potty slowly gives rise to painful hard stools. After a single episode of painful defecation the child associates this pain with the act of defecation and simply refuses to pass stools even in a diaper.
This sets in a vicious cycle of refusal, stool hardening, and painful stools.
Stool toileting refusal Vs stool Withholding
These terms are often confusing, although sometimes used interchangeably there is a fine difference between the two.
Stool toileting refusal is refusing to pass stools in the potty or toilet while comfortably urinating in the potty. These children often insist on wearing diapers for defecation. The main problem here is the fear of potty chair and not necessarily the act of defecation.
Stool withholding is the voluntary withholding of stools irrespective of diaper or potty chair, by using different maneuvers which eventually hardens the stool and leads to constipation. This occurs as a gradual progression from stool toileting refusal.
How common is stool with-holding?
Stool toileting refusal is seen in one in five children and is more commonly seen in boys than girls.
A child less than 15 months cannot withhold stools and therefore is more likely to be suffering from medical problems.
A child who withholds stool is usually between 2 and 5 years and is capable of understanding toilet training procedures like needing to use a potty chair but simply refuses to do so.
How to recognise stool withholding behaviour in my child?
Stool withholding as discussed above starts as stool toileting refusal and preference of the comfort and familiarity of diapers.
Parents who are toilet training see this as a setback in their training process and therefore insist on using a potty or toilet seat. This tug-of-war eventually leads to the child preferring to hold the stools in rather than displease the parent.
Stool withholding can be recognised by the maneuvers the child uses to postpone a defecation event. The child can exhibit following behaviors:
- Hiding when she senses an oncoming toileting need.
- Stool withholding maneuvers: Doing what is commonly referred to as the ‘potty dance’: leg crossing, turning red while stiffening legs.
- Soiling of underwear either small stains due to overflow or whole bowel motions known as stool incontinence.
Increase in day time and night time bedwetting episodes.
Why does my child withhold her poop?
There are several reasons for children to exhibit stool withholding behaviour including behavioural and medical reasons.
Behavioural causes :
1. Painful Stools
A child, in general, has aversion to any painful or uncomfortable experience just like any adult. A child’s first painful poop becomes the starting point for stool withholding.
This is the most common reason for stool with-holding behaviour in children.
One episode of painful stools initiates a vicious cycle of stool withholding, constipation and in turn harder stools.
2. New environment
Stool withholding occurring in a child who was previously passing regular soft stools in a designated place like potty or toilet seat is usually because of starting a new school or new daycare centre.
Children, especially those below 5 years, are beings of familiarity. They like consistent patterns in terms of place, things and people around them.
A new environment is intimidating to a child and any toileting need is postponed to avoid using the potty. This eventually gives rise to constipation and hardened stools which become painful to pass.
3. Multiple caregivers
Being able to give continuous care and attention is a luxury many mothers cannot afford these days as many mothers are working.
Our social situation has also gotten complex where nuclear families are the usual norm and therefore non-availability of grandparents for childcare.
This complicates toilet training as children are shuffled from one caregiver to another. Many times many members of the family as well as daycare workers are involved in the caring of the child.
This creates an inconsistency in the toilet training process.
Not having a uniform system the child struggles to find ground
4. Delayed and prolonged toilet training
If it is not late already, do not delay toilet training for more than 40 months.
Studies have shown that toilet training that was started at a later age is more likely to be associated with stool toileting refusal.
In one study more than 50% of the children who had stool refusal had started training between 40 and 42 months which was much later than those children who were able to successfully toilet train.
5. Toilet training methods: Coercive vs non-coercive methods
There are numerous toilet training methods. All these methods can be broadly classified into two categories: Coercive and Non-coercive methods.
Coercive methods are mostly ‘parent oriented and regimented. They require the parent to actively coerce a child at regular intervals.
Non-coercive methods are ‘child-oriented and slow-paced. The child is given the freedom to take training at his own pace without any strict structure.
Children who are toilet trained with coercive methods are more likely to develop stool withholding as compared to those trained using Non-coercive methods.
While urination occurs quite spontaneously once the child sits on the potty, defecation requires some effort from the child as well as patience. Children who are accustomed to running around get bored sitting on the potty. This starts acting as an aversion that discourages them from taking the throne.
Children who are active and playful hate being seated on the potty chair and find it easier to postpone.
7. Using a negative description of potty
Some parents either intentionally or unintentionally use negativity to describe toilet-related tasks. FOr example describing pooping as a ‘dirty job’, grimacing on seeing the poop or smelling the poop.
This creates a negative association between the act of defecation and the child. Children inherently want to please parents and they assume they are avoiding any displeasure to parents by avoiding the task itself.
Medical causes :
- Hirschsprung’s disease
- Autism spectrum disorder: many children with autism spectrum disorder may also have sensory processing disorder which can make them under or over-responsive to any sensory stimuli. The sensation of pooping might cause under responsiveness from these children causing stool withholding and constipation.
How do I stop my toddler from holding her poop?
We are going to give a step-by-step approach as to how to break this cycle of stool withholding and constipation.
Step one : Disimpaction
Treat constipation aggressively
If your child hasn’t passed stools in days it more likely that the stool has hardened and it is going to be painful for the child to poop.
So the very first step would be to treat constipation first. Your pediatrician will resume a disimpaction procedure to relieve the hardened stool.
This usually involves medication and sometimes rectal enema to soften and expel the hardened stool, followed by maintenance medication like stool softeners for the next few weeks.
Step two: maintenance and prevention
- Plenty of fibers and fluids
Once your child is relieved of the hardened stool it would be wise to take aggressive measures to prevent constipation in the future.
This involves including lots of fibers and fluids in the diet of the child.
Use fiber-rich diet composed of lots of fruits, raw vegetables, whole grains, nuts, seeds in the diet.
Step three: Back to square one
Back to diapers:
If your child is suffering from a fear of pooping, whatever the cause might be, it is ideal to take two steps back in your toilet training regimen and put them back in diapers.
Your child has been pooping in diapers for his entire life and is most comfortable returning to them. This downgrading should be done without shaming the child in a matter-of-fact way.
You should not only put them back in diapers but also praise them when they successfully poop in them.
Remember, diapers are not the problem at this stage, your child withholding poop is. So, give them praise and rewards every time they poop successfully in the diaper.
Withhold toilet training for at least a month or two.
The greatest gift that children have is that they have the ability to relearn anything.
Withhold toilet training until your child is back to her own self with regular pooping and is free of any hard stools without the need for stool softeners. This should usually take about two months.
Re-introduce toilet training in a more gradual and phased manner.
It is best to re-evaluate your toilet training style and take a more gradual approach to toilet training. Try a more ‘child-oriented- method that allows your child to feel like they are in charge of the process.
Allow them a bit more freedom to experiment with the potty tools.
Invest in a new potty chair!
When you are restarting your toilet training ensure you have a supply of new things including a new potty chair preferably picked out by the child herself, some colourful and exciting potty training board books, a new doll, some fun activity books to keep her occupied while on the toilet.
It is very important to note that you should not use the same old potty chair to restart training. Your child has already created a negative association with the chair and is more likely to continue to be terrified by it just as much as she did the last time.
So reintroducing it is only going to be met with more tantrums and a brand new series of complications including stool refusal and stool withholding.
Reward system: Points chart or Rewards sticker
Rewards simply mean anything that will get the child excited enough to repeat the same process again and again. It gives them an incentive to re-do the same task.
Rewards can be anything from praise, hugs, kisses, high-fives, applauds to stickers. We do not recommend using sweets as rewards as this may encourage unhealthy eating habits.
Never- use the negative term for toilet training
Praise the child for every successful defecation even in the diapers.
A study was conducted to see the effect of not using any negative terminology and praising the child for toileting efforts in the diaper as well which showed that the parents who followed these instructions were able to toilet train much sooner than other parents.
What are the complications of stool withholding?
Stool withholding causes stool to be backed up in the intestines and eventually the rectum.
- Urinary tract infections
- Soiling (encopresis)
- Abdominal Pain
- Decreased appetite
But these are short-term complications and can be easily treated with the involvement of a paediatrician.
Studies have shown that there is no risk of behavioral problems in children with stool toileting refusal as compared to normal children.
My child passes urine easily but refuses to poop?
The reason for this is more about the anatomy and the physiology of our body than behavioral differences. Bladder movement is usually difficult to withhold especially for a child with limited bladder capacity.
While sometimes it can be withheld for short periods of time most often it results in dribbling and incontinence.
Whereas stool with-holding can be withheld and postponed for prolonged times. It in fact becomes a vicious cycle: the more the child with-holds the more he can continue to do so.
The urge to defaecate usually passes after some time, unlike urination which grows stronger with time.