Episode 18: Does your child avoiding pooping? Let's talk about withholding!

In this episode of Ask Dr Jessica, our guest is Naama Cameron, Child Behavior Specialist.  Naama specializes on the topic of withholding stool, which is when a child holds in a bowel movement instead of allowing it to pass out of the body.  If done for long enough, stool withholding removes the “urge” to poo, and the child then feels short term relief that they have avoided their fear.  Many toddlers withhold, often during the potty training, and parents are at a loss for what to do.  Naama gives great advice on how to make it all come out okay in the end (pun intended!) :)

Naama Cameron, MS is a Parent Coach and Child Behavior Specialist.  She is an incredible coach and resource to families, especially with the topics of potty training, social coaching and behavior counseling.  To find out more about Naama, her website is: www.naamaparentcoach.com and you can find her on Instagram at: naama_parent_coach.

The host of Ask Dr Jessica,  Jessica Hochman MD, is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children.  Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner. 

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Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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Transcript

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Hello everybody and welcome to this week's episode of Ask Dr. Jessica I am your host Dr. Jessica Hochman. On this week's episode I have a lovely guest for you nama camera. Nama is a behavioural specialist. And on this episode, we particularly focus on what to do when your child has behavioural issues around using the toilet. I hope you enjoy this episode. And if you did, I would really appreciate it if you were to leave a five star review. Now on to the episode. Hello, hello and welcome to this week's episode of Ask Dr. Jessica today we have a very special guest now my Cameron. Hi everybody. Hi. Nama is a parent coach and she works as a behavioural specialist. So I'm really excited to talk with her pick her brain and discuss a lot of the behavioural concerns that I hear from parents. So NAMA, maybe we can start with tell us how you got into this field? How did you become a behavioural specialist. So I worked in the school psychologist and didn't really feel like that was my niche because I didn't get to do as much hands on with the kids as I wanted to. And then I went into teaching and my final year of teaching, I spent so much time helping parents set up good systems in their home, that I thought I could go and do this. And I just started my own practice. And organically as the time went on, I started specialising in certain things. And one of those things is withholding. It's one of my areas of expertise. Can you explain so what is withholding? Exactly? When you say withholding? So withholding is kids that whether they withhold their poop, they won't go in the toilet, maybe they'll hold it all day, they won't go to school. It could be poop, it could be pee, they can go every day, but they're having accidents. They can go every couple days. It's just it's it's such a spectrum of what that looks like. But essentially, it's just not going regularly in the toilet consistently. Okay, and did you notice when you were working with families that this became a common theme? This is how you gravitated towards withholding? Absolutely. And I will tell you since COVID hit you know, before COVID, it was probably about 60% of what I was doing, you know, was kids withholding. We're now it's about 90%. Wow. Oh, yeah. percent. Wow. That's interesting, because sort of, you know, as I think about it, when I talk to families where kids have issues with going to the bathroom, sometimes I wonder if it has to do with school, you know, whether or not they're afraid to use the restroom at school, or they, you know, maybe have, they're embarrassed to ask the teacher and they don't want to ask permission to go the bathroom. So it's interesting that during a year where they're home more, you've noticed more issues, when you know, I think it could be parents are a lot, because parents are with their kids so much that they see it a lot more, they're way more affected. I also, as expected, parents really laxed on the boundaries and the rules, and let kids do a lot more than we would have before. And I think that and we'll talk more about that. But when those lines get blurred, and kids feel like they have to control more, that's where you see the withholding come out more interesting. Okay. Now, now sort of backing it up. When I think about little kids, you know, we're expecting that they're going to have problems with the restroom, or, you know, they're learning how to use the restroom. It's a process. So when you talk to families, is there a certain age where you tell them this is normal? At what point does it become something where they should reach out to someone like you a behavioural specialist. So usually, I would say around three and a half. And I'll tell you the two common threads that I see. With these children, there's usually something and I'm going to say traumatic, very delicately that happens for these kids have maybe they didn't go for a couple days, and then they had a really big poop and then that stopped them from wanting to go in and then starting to hold it. And then that pattern getting reinforced and continuing. Another trigger that that I see very common is that parents will say okay, well I'm just going to wait until my child's ready. And if there is no healthy encouragement, and a certain kind of personality mixed with that, you're gonna have a child that's just, you know, you're gonna wait till five and a half and then the parent says, well, they don't want to go they're refusing to go or they'll only go in a pull up. Interesting. Okay, so some more out of becomes A pattern or something that they're used to? Yeah. Okay, so, so just for parents listening out there, when can you talk about, and I can chime in too with this. But when is a normal? What's the range of potty training, you know, for example, for paying for pooping for girls, for boys, what sort of the normal range that you expect to see. So and this was even with my own children from about 18 months, till I would say by three, my son was potty trained by 18 months. And that was just because I was very in tune with his cues. And I didn't force but I also encouraged and I and I was very mindful of not making it a power struggle. And what happens is a lot of times, is withholding is connected to a power struggle. And it's something that we as parents really can't control, we cannot control our kids bowel movements. And they can and so the more that you have that battle, the more that the kids continue to withhold. So I, I was very mindful, as soon as I saw that, my son, this interested, he knew when he could feel it in his diaper, I also helped him be very independent in the process, I gave him a lot of control about it. And, and really minimise the pressure, but a lot of encouragement. So I would say between 18 months to three years old, is that window, if you miss that window, like I said, that's when you have a lot more challenges and you have a lot you know, that power struggle and have been holding. Okay, alright, so just um, so So I just to tell parents what I how I present potty training, I usually see a females on average, they're trained with their with urinating, usually around, you know, two years, three months, two and a half, sometimes closer to three. And the boys tend to be a little later, you know, a oftentimes two and a half towards even three years old. And for stooling, or for pooping, it tends to be closer to three, and if not, if not beyond. And I was always taught that before, too, it's really tricky to potty train because kids can get mixed messages. So that's interesting to hear that you had success at 18 months. Sometimes parents will tell me these stories that they're trying to potty train when their their child's nine months old a year, and they'll put them over the over the toilet. And I feel like that's definitely too young. You know, it seems the kids are very smart, and very aware and very in tune. And I feel like sometimes we don't give them the amount of credit that they really deserve. And like I said, if you're just very in tune with your child, and you can see, you know, what, my daughter was a little bit it took her a little bit longer than my son, ironically. But I could tell that he was uncomfortable. As soon as he had pee in his diaper, I could tell that he was interested in the toilet, we would go sit in the toilet and it was very fun and it was more curious. And then organically I followed that. Unfortunately, what happens if parents tend to back off that and they don't follow that when they put too much pressure, then that's when you get the issues. Okay, so your overall message to begin with for parents is that follow your child's cues without pressure. But if they lead you follow those cues, absolutely have a total have a little toilet out so they can go sit on it. They can discover it. You know, I had one since they were babies, they were just always looking at it and playing with it. And it was just there. Oh, do you want to sit on it? Do you want to try? No pressure? Nothing. Okay, yeah, no pressure, keep it light and easy. available if they want it. Exactly. Okay, so so so if you were to give a parent a message about how to begin to make their children feel comfortable with the with the potty, do you have any other tips in terms of you know, in addition to providing a party for them to sit on anything else that would help? book you mentioned less pressure books, okay, good idea and role modelling. Not making the bathroom such a big deal. You know, I always went to the bathroom letting my kids see me, it being very normal, you know, kids are curious. And the more that they know about things, the more comfortable they are so modelling. Now, well, I'm sure we'll talk about this later, but we do have to model it appropriately. And we talked about having the bathroom, the little potties available. But oftentimes what I see with my families is that those little potties are all over the house, and they're in the living room and they're in the kids play room. And that's not what we want. We want to really set the tone that all this toileting stuff that goes on goes on in the bathroom, not anywhere around the house, but it goes in the bathroom. Okay, all right. So so let's that's that's smart so that they know specifically, this is where toilet training happens or repotting happens. That makes sense because Later, later down the line, what happens is, if my families will say to me, Well, we let them use the toilet in the living room, or we let them use and so what you're doing is you're in, you're allowing them to be sort of lazy without potty training. And that's not what we want to do. Okay? All right, so let's, let's talk about that first situation you were describing where a child has a bad experience, they wait a couple of days, and they go to the bathroom. How would you advise a family like this, so So if you notice that a child starts to go less frequently, and it's painful, when they do go to the bathroom that's causing them to hold in? How would you guide a family in this situation. So usually, at that point, they will go see their GI, just to make sure that everything is moving, okay, and they're not backed up too much. And at that point, the GI will recommend, you know, a stool softener, maybe MiraLAX. And that will help the system go. So you're taking care of the physiological part of it, the the important part that my focus is on is the emotional part in that not making it such a big deal, not discussing it so much, not bribing your child over and over again about this, I'll give you this, I'll give you this. And as soon as you give it attention and power, then you're turning it in, you're reinforcing that pattern of the child withholding. Okay, so, so what you notice is that, you know, I would think that a lot of children, so the way I understand it, is that we can cause a vicious cycle where if kids, you know, oftentimes will see constipation around potty training. And if they have a bad experience, and it's painful to go, when they have an urge to go poop, or to use the restroom, they'll sort of squeeze and clench and hold in, and eventually that urge will pass. And then when they finally have enough stool, and they have to go, it does hurt. So it becomes this cycle. So I you know, what I think you're what you're saying is interesting, I thought they were we're holding in more based on fear of pain, but you're saying it can turn into a form of control in some circumstances. 100% 100%. And then what happens is, when they are crossing their legs, or they're, you know, rolling around trying to hold in their poop, parents have a big reaction. And what happens is, it's so emotionally triggering. And I understand I mean, I know, withholding brings emotions for parents. And, you know, I always like to say parents are not alone, because so many parents do experiences, and there is guilt, and there is shame in there's so many emotions of the parents that we feel when we see our kids doing this. So I think those emotions get put on to the child and you kind of feel this desperate, like I need you to go and all this pressure and discussion. And oftentimes, what happens is, that child who's withholding becomes the centre of the entire family. So all of this attention is given to this child who is withholding who's rolling on the rug, who's uncomfortable crying in pain, and parents are essentially begging their child to go to the bathroom. And that pattern is reinforcing that negative behaviour. That's so interesting. So at some point, it can, it can mix, it can turn from being constipation, and blend with some attention seeking behaviours. And it works because parents are so triggered by it. Right? And, you know, as soon as you know, and I will tell you, nine out of 10 times, these kids have strong strong personalities, and they've got a strong will, and they know what they want. And it goes hand in hand, I see it oftentimes. And so there has to be a healthy balance of the amount of control that these kids have compared to running the show. So what should a parent do then if they're, you know, if they're, it makes sense, you know, for for health reasons, we want to see kids go to the bathroom. How should a parent approach this? If you know, giving them attention for it isn't going to help matters? Should they ignore their children? You know, how, what's the right? What's the right message we should be giving to parents. So there's their steps to making children who withhold or they poop in up, pull up their steps to have them take no responsibility for that, where it's not so much a power struggle. And what that would look like is, you know, having kids be a part of the changing process. You know, I tell parents, All kids should be changed in the bathroom at that point, you know, we're not talking about a nine month old, we're talking about a three and a half a four and a half a five and a half year old. They should be changed in the bathroom. Oftentimes I have you know, five Five and a half year olds that are being changed on changing pads. And we're the message that we're saying is we want you to act like a big boy or big girl, but we're not going to treat you like one we're still going to. So it's about having them be independent, be a part of that changing process, and also not getting it attention. So an example is if a child is laying on the ground and holding their stomach and crying, I would say, oh, you know what to do? If you want to make yourself feel better, and then put it on them? You're empowering the child Exactly. And letting them know this is your decision. This is your control. Okay, now what what about this is a question that comes up all the time, there's a lot of kids that, you know, they learn how to urinate or pee on their, you know, in the in the in the toilet, but pooping comes later. And one example I hear often is that children will ask to poop in there pull up, they refuse to go on the potty, they want to go, you know, they'll hide in a corner and they'll go, they'll go in there pull up. And parents don't know what to do in that situation. What, what do you advise families, when their children refuse to go in the toilet, they know they're capable of, you know, sensing when they have to go to the bathroom, and they want to be in a pull up? Do you think we should just let kids continue on that way? Or should we? What should parents do? Great question. So and this is, this is the first step and really helping kids be more comfortable going in the toilet. I say put the toilets in the bathroom, when your child has to go, they go in the bathroom independently, so they're not getting one on one attention from the parent, they go in the bathroom, they put their pull up on the poop. And then they call you in and they are doing most of the changing, obviously, whatever we have to do to make sure that they're clean, but they need to be the ones taking off their pants, you know, helping with a pull up throwing it out wiping, they need to be a part of that process. And I tell parents, during that changing time, limit the amount of discussion, because that it turns into one on one time. The parent is in the bathroom of the child to have an even though it may be negative and you know, to parent, it's like why would this be reinforcing to my child? But it is because you're not working? You're not with the other kids, you're giving your child's undivided attention. That's what they see. And that's what you want to avoid when it comes to this. That makes sense, because I know you know, Psych psychology really. It plays a big role with children. And I know that they'll do anything for attention, be it negative or positive. They just like you, they'll they'll they want their parents resources, they want our attention. So that makes sense to me. Absolutely. That's so much of it. And again, like I said, by the time these parents call me, I mean, it's like, they'll say to me, the whole weekend revolves around this child and their bathroom. And we can't go anywhere, and they dictate where we go. And there's so much control and attention around it. That is just reinforcing that child. And let me tell you something, usually by two and a half, or three, these kids know the signals, you could tell they're touching their pull up, you could tell they're saying PP, or they're communicating that they want to be changed. I would tell you, I've never knock on wood. I've never had a child who has been anything other than behaviour. It's never been anything more. It has always been behaviour control. And the second we change it, and we change the dynamic between the parents and the control. They're done. Interesting. So you're saying initially send them to the GI to make sure it's not physiologic Oh, wait, that's not that's not the answer. It generally speaking, and I've had parents to do TestS and TestS and TestS, and I always say it's behaviour, its behaviour. And they'll come back and say, okay, it is behaviour. So if a child is showing signs, you know, there's nothing wrong with not pressure, but a good amount of encouragement. Okay, well, we're gonna take the pull up, off, or maybe you do it gradually, maybe you do it for a couple hours, and you're monitoring and you're taking them to the bathroom, you can use some sort of reinforcement. This is a time when it comes to toilet training, that I'm like, Okay, if you use, you know, an m&m, a Hershey Kiss, whatever it is to get your kids comfortable, because it almost is like a desperate measure for parents. If you miss that window, it's just, it's really tough. And it's hard to backpedal and fix that up. So I always say like, start if you can, and if you miss the window, you just got to make sure that you're not reinforcing that pattern. So so just to make it clear for parents listening, because I do think there's a time that's too soon and I think there's a window that's too late. What What should parents look for when is that proper window? So like I said, if they want to be changed, if you could tell that they're uncomfortable there. They're showing you that they're uncomfortable because they're wet, or, you know, they went to the bathroom, they're touching it, they're curious, they're putting up on their own pull up. These are little cues that say, okay, my child's interested in let me go with it. What I'll usually tell parents is, it's too soon to start if they're not bothered by being in a poopy diaper, that once they care that they're sitting in poop, and they don't like it, that's a really good time to initiate potty training. So I think that works, in some cases, but what happens is, parents will call me and they'll say, my five year old, my six year old will poop in his pants, and he doesn't care. Okay, and so, you know, I say to them, that is not unusual. Some kids, yes, it'll bother them. That's how my son got trained, he could not stand the ceiling. And so he, he was like, ready to go. But some kids are okay with it. Some kids could sit in it, they maybe they want to play, they don't want to stop playing this sensation doesn't really bother them. They're not paying attention to it. So it's, it's like a 5050 with that. Okay, and a lot of parents have different methods in terms of potty training, you know, you hear about the three day boot camp and the, the no diapers all weekend method and, you know, gently, gently encouraging them, do you have a preferred method for potty training, or I think it just depends on the child, honestly, there are some kids, you know, and that's what I think also is confusing for parents is one sibling can follow the three days pantless, and they're fine. And then they try that with their other child. And they're just like, it did work, like all hell breaks loose and didn't work. So it really depends on the child, I think, you know, the ones with a stronger personality are the ones that had some sort of traumatic event with a stool that you know, they get constipated, is a different approach. And that it's not going to be a three day that's it, we're one and done, it's, it's more of a gradual, let's make this process inconvenient, organically, you're going to have to be more independent in this process, you're gonna have to go get your pull up, you're gonna have to change your pants. Give them more of that. So to a child, it's like, Oh, I'd rather just go on the toilet, then do all of this extra work on my own. These these families that you see that you've worked with, were withholding as an issue. Do you notice a common thread in terms of the dynamic between the parent and the child or the personality types between the parent and the child? Most of the time, it's, and I love these kids, because they're just, they're smart, they're savvy, but it's your strong personalities. It's the ones that like their way, the ones that, you know, will argue will power struggle, they run the show, they, you know, have tantrums, it's just, I see a lot of the same themes. And that's why I always tell parents, the bathroom and then withholding is just one aspect of it. You know, if you target the entire behaviour, then it's easier to manage the bathroom. And that's a, that's what I really encourage my families is set up some boundaries, have some clear structure around the house, be consistent, that will help your child not need to feel like they've got to control. Do you have any general advice for parents to deal with kids like this, anything else that we didn't, you know, take a breath, because it will get resolved. I just you know, it breaks my heart because by the time parents come to me, they're just they're broken, they're overwhelmed. They're so stressed, they're so drained, and it becomes their dynamic, it becomes a relationship with their child. So if I could just say to you take a breath, you know, step out of it, try not to give it so much power and ask more matter of fact about it and put it more on your child. That's the best advice I can give. That's great advice. I know, we always say, you know, by the time they're walking down the aisle, they'll be out of diapers. It's true. But I think in the moment it's so triggering for parents and parents have tried everything weed they punish. And I don't I will tell you this, I do not recommend ever, ever, ever punishing your child for withholding or having an accident. The amount of shame that comes with that, and it has never, ever helped a child go to the bathroom. It does not. So I don't recommend that at all. It's hard though, because I think in the moment, for a lot of parents that make sense. You know, pooping isn't in public, it's not fun or if the if the, you have to change the sheets in the middle of the night or, you know, it's messy. So I think it's hard for parents not to hide. You know, not to hide their emotion that they're not totally thrilled with the behaviour. And I think in those moments too, they're just like, well are you doing and you know better in that whole conversation? does nothing. But if you put it on them and say, Well, if you don't like doing this, it's up to you, you can make that change. It's more about empowering your child and not making it a power struggle or about you and your emotions. Okay? And what's your experience? Like? How long does it usually take kids to, to improve with this behaviour? So there's a range, but what can parents expect? It varies, I will tell you, I have been very successful with this, I have a whole little thing I do with kids, this whole little programme, but usually, it's pretty fast. Now, once in a while I do have to go in the home and help. You know, but the what helps this process go much faster, is having the parents there dude, do their part. And for the parents to really set up a Healthy Families dynamic with some clear boundaries, some clear rules. And there is a separation of parents and child. So the child feels like, Oh, I get to just be a kid, I don't have to be in control of everything or be in charge. That helps the process much faster. And the parents not giving so much attention. I can't tell you how, what a big part that plays in all of this. I would say that's probably the biggest takeaway parents don't give withholding attention. Don't give it power act very matter of fact. I think that's, you know, really good advice. And I, but I also feel for parents, because sometimes they'll tell me, it's been hours, you know, or their child hasn't gone. And it's been days. And it's very distressing. Very, I mean, my heart breaks when parents call me because I know where they are emotionally. And again, in our head. It's like, why would our child want to suffer? Why would they hold it in for so many days, or they worry about, you know, the long term ramifications of this may had. But we still have to put all of that aside in front of our kids, as hard as it is. And I say go in the room and complain to your significant other, but don't let your child know that you care. Okay, so less, more, less negative attention and try to bring on more positive attention it sounds like and for that bathroom is just really unemotional really matter of fact, like, oh, okay, we need to go change, let's go. And also, part of it, is to really encourage your children to be independent, and know what they really can do. I have a lot of parents when I say that they're three and a half year old, are they getting themselves dressed? They're like, No, I don't think they can. But they can. And the more that we encourage our kids to be independent and build that confidence, the more they're going to want to make independent choices like going to the bathroom on their own. It's so true, I think. I'm always surprised what my kids are capable of doing. You know, if I let them pick out their clothes and get dressed and put their dish in the sink and use the restroom and brush their teeth, there's so much that they're capable of, but I know if I do hold their hand and get them dressed and put their shoes on, they're happy to take my assistance. Of course they are You're right. And parents, that mean, you're right, you're spot on, we're always surprised at how much our kids can really do. And that's why it's so important to give them the opportunity. And even if they fail, and they get up. It's a great learning lesson. Right? So let's say you know, so I'm a kid and I'm withholding and, and I'm withholding my poop and I haven't gotten a couple of days, a parent puts a pull up in in the bathroom and a potty in the bathroom. And what should a parent do next? Any any? So what's the next step? Your let's say what? Your three and a half? Four? Yes, even five, even six. Okay, so at that point, the little potties out, okay, because the expectation is again, we're asking you to do big girl things like go poop on the toilet. So we want you to go on a regular toilet. I'm going to also tell you another trick I've learned. These little potties kids can sit on for hours and never go. If a kid is sitting on a big toilet, it's a lot harder for them to hold in their poop. So the longer they sit, and the more that they're on a regular toilet, the more likely they are going to go. Now, I would say to you, oh, you know, we you can make a choice. You can either go in the toilet or you can go get a pull up and go in the bathroom. When you're done. Let me know and let this be an independent process. I have seen many times kids organically just start using the toilet because again, it's like, oh, you have the choice. You can either go in the toilet or you can go in the pull up, but you're by yourself and you're doing this on your own. And I think that's an important message to send to kids. And kids are very smart. You know, they know they see what their friends are doing they they will Want to do organically what their friends are doing, they will want to organically do what's easier, and that's to go on the toilet. And then when they're done, they are really doing most of the work. You may be in there just to make sure that they're clean. It's great. I know it's interesting how many how many people out there are hyper focused on their children's peeing and pooping rabbits? I mean, I have gotten logs. I mean, it's it's so funny because it's just I've we've talked about everything about poop, and it's always parents are always uncomfortable for some, like, I've heard it all I know size, colour, texture, all of it. Nothing fazes me. It's just it's like a normal conversation. And everybody poops, everybody poops, everybody poops. Alright, so I like this. So the big picture here is be to encourage them, empower them to do it independently. But to try not to make it a big deal. less attention over there pooping and peeing habits, very matter of fact, very unemotional. Is there any advice that you can offer to parents that we haven't covered yet? Any any last? Thoughts for families if they're going through this? I feel like the main thing is to really set up your house with boundaries and rules. So parents are in control, and that the kids feel like their parents follow through with their word, so that kids can just be kids and not feel like they have to control everything. And again, just be unemotional. Don't power struggle with your kids. And again, have expectations that you go to the bathroom in the bathroom. Sounds great. Like the advice and you will get through this. You will get through this parents, I promise you. Thank you so much. Thank you very much.