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Stool withholding in school-aged children – when your child ‘isn’t toilet trained’

School. It is meant to be a word that evokes excitement, anticipation, a rite of passage and (dare I say?) a new freedom for dedicated, committed parents.

But for children with chronic constipation, encopresis or stool-withholding challenges, the thought of school can trigger feelings of worry, anxiety, fear and even downright dread.

Many parents go through varying degrees of stool withholding and constipation when their children are embarking on the journey of toilet training. For a large percentage of toddlers, this is a short hurdle that is easily overcome. A few stickers on a reward chart, some awesome spiderman undies and the lure of a chocolate reward usually see children conquer this milestone with a minimum of fuss.

But for many families, stool withholding and constipation is a chronic, stressful and challenging condition that can persist well into the primary school years.

Stool withholding in school-aged children

What is 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 poo. The child then feels short term relief that they have avoided their fear. The child then repeats this action the next time they feel the urge to poo. This vicious cycle then causes a build-up of old, hard stool in the colon, which then presents like constipation.

Imagine your biggest fear

Imagine your biggest fear. Let’s say it’s a fear of heights. Would you like to talk about it with others? Probably not. Would you like to live on the 25th floor? No way. If your friends were going hang gliding, would you go or make up an excuse to avoid it? Imagine if you were told that you HAD to go hang gliding after dinner every single day. No doubt you would feel quite worried or scared and perhaps even experience physical symptoms such as a racing heart or feel the urge to ‘run away’.

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 as adults do when faced with their biggest fear – they try to avoid it.

When left untreated, stool withholding can become an ingrained, habitual and ‘normal’ response for your child. The longer the cycle continues, the more difficult it is to break.

What can stool withholding look like in my school-aged child?

While every child is different, there are some subtle signs that your little one may be experiencing fear around pushing out a bowel motion:

  • Fear of using the toilet, particularly at school, at friend’s houses or school camps
  • Hiding soiled underwear
  • An increase in wee accidents or bed wetting, as the full colon is pressing on the bladder
  • A noticeable odour which your child does not notice (as they become accustomed to the smell)
  • Physical signs such as stiffening the body, crossing their legs or turning red-faced to attempt to hold in their poo
  • Withdrawal behaviour, such as social isolation, withdrawal or reluctance to attend school

How do you treat stool withholding in school-aged children?

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 Paediatrician can provide education around administering laxatives for your child. This will help to keep the stools soft, making them easier to pass.

Tackling the emotional issues around stool withholding are crucial to moving forward. Try the following:

1. Liaise closely with your child’s teacher

Close communication with your child’s teacher is essential. Arrange a meeting and provide the teacher with information detailing the issue. Come up with a plan of how to help your child at school – this may include preparing a ‘pack’ of wipes and spare underwear to be kept in a private bathroom, coming up with a subtle signal system that you child can use with their teacher or providing regular bathroom visits.

2. Focus on pushing out the poos – not toilet training

If your child is withholding, going back a step to focussing on pushing poos OUT can be very helpful. For now, at least, pack the potty away and forget the toilet – passing bowel motions in these places are LONG TERM goals for your little one. Start by supporting your child to have repeated exposure at pushing out pain-free poos. This can be into a nappy or a pull up standing up, or whilst wearing undies – anything that helps your child feel at ease.

3. Find a ‘reward system’ that works

Find your child’s internal motivator – is it that new box of LEGO? A pretty barbie doll? Create a ‘points chart’ with your child – for every poo they push out, they get five points on their chart. When they reach 15 points, they get that reward.

4. Use a social story

Social stories are simple stories personalised for your own individual child. They help to explain different procedures and social situations in simple, everyday language. A free, editable social story relating to fear of toileting and pushing out poos can be found in the author bio at the end of this article.

5. Seek additional support

Stool withholding can be an all-consuming, daily struggle for the entire family. It can be very helpful to seek the advice from an objective outsider. A psychologist can provide some wonderful strategies to help your child work through their fears relating to stool withholding and help to talk about the issue openly.

Stool withholding in children is a confusing, silent condition that can be extremely challenging for families to navigate. The good news is that there can be light at the end of the long, dark tunnel and with the right resources, we can help support our little ones to feel calm, feel safe and ultimately thrive.

References:
Ferguson, Sophia J. (2015). Stool withholding. What to do when your child won’t poo! London: Macnaughtan Books
https://www.childrens.health.qld.gov.au/fact-sheet-faecal-incontinence/

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