A problem that captures the complex intermingling of biology and psychology is the problem of chronic constipation and soiling in young children. This is not an infrequent complaint of parents in my practice.
Often chronically constipated children had initial difficulties in toilet training, for example, refusing to poop in the toilet and demanding a diaper, even sometimes insisting that their parents put a diaper on them just for this function. Sometimes the children seem to be afraid of pooping in the toilet, fearing the loss of their poop as if it were still a part of their bodies (a common confusion related to the child’s cognitive immaturity), or fearing the swirling of the water taking the poop down into some unknown place, and the noise of the toilet flushing. These worries are common and not “abnormal” and only cause problems when they become extreme and chronic. Often children cannot articulate why they are afraid or do not even know what they are afraid of. Instead, they can appear to be obstinate.
Children also typically fear a loss of control in relation to defecation. Again, the fear of losing control only becomes a problem in extreme cases. Sometimes children feel more in control of their bodies and body experience if they can maintain their infantile habit of defecating in their diapers. Loss of control of their bodies can get mixed up with fear of loss of control of inner feelings and impulses, such as angry feelings and aggressive impulses. According to this (unconscious) reasoning, “letting go” refers to more than the child’s anal sphincter, but also to what the child perceives as a destructive, internal ball of anger and aggression that can explode outwards if the child doesn’t hold on tight. The child’s fear of letting out the “bad stuff inside” can cause her to fear loss of the caregiving relationship, or – in concrete terms – the disappearance of the parent! You can begin to see how a process as universal and commonplace as toilet training can hide within it dark and complicated fantasied dangers!
The child’s sense of losing control of his poop can blend into the control struggles all children and parents sometimes succumb to when parents have to set limits on children’s behavior or demands. So toilet training can become a battle of wills. Interestingly, this is more often the case when children have additional reasons for feeling out of control – when they have developmental quirkiness that makes them more emotionally fragile and more dependent on their parents, when they have sensory over-reactivity that makes them constantly uncomfortable in their bodies, when they are generally timid or fearful, or when there has been a recent loss or disruption in their caregiving relationships. Again, children often are not aware of the feelings and frightening beliefs that cause them to resist their parents’ entreaties. They just refuse to comply.
A common consequence of children’s fears of pooping – whether related to their fears or to established struggle patterns with their parents or both – is that they withhold their poops. This withholding has biological consequences. A fecal mass can accumulate in the child’s rectum and colon, distending the abdomen and giving the child a tummy ache. As the poop loses water in the large intestine, it becomes hard, and this plus the large size of the accumulated feces, makes it very painful to poop. Of course, this pain increases the child’s fear enormously! In addition, newer liquid stool can leak around the hardened stool in the rectum and cause soiling. Usually the child is unaware of this when it is happening, but it can cause big problems in school and at home.
A wonderful explanation for how withholding stools causes distention of the rectum and loss of the impulse to defecate is given in the website gikids.org. I would highly recommend the “The Poo in You” short video on this website that can help parents and also some children understand the mechanics of the process and how to develop healthy habits. Sometimes medicine can help soften the stool and draw water back into the colon and rectum to facilitate the passing of the fecal mass.
The video also emphasizes the fact that it takes time for the rectum to recover from this distention – as long as a year of treatment. This is important because sometimes in my experience, doctors and parents discontinue the treatment too soon, with the result that everyone gets discouraged when the symptoms come back. Of course, it is not only the rectum that needs time to recover; the child needs time to “practice” the new and healthier way of pooping, and the parents need time to practice supporting their child in doing this.
Psychological and Biological Factors are Interdependent
Sometimes the child is so afraid that even when good medical treatment has been established, he or she cannot “let go” of the poop. Then, a psychological helper (therapist) is needed to diminish the child’s frightening fantasies of “the bad stuff” inside of him or her – ideas of poop mixed up with the child’s angry feelings and aggressive impulses. These “fantasies” are not in the child’s conscious mind and are not usually even coherent thoughts. This therapeutic work is done in play therapy in which the therapist engages the child in pretend play with messy, angry, and aggressive themes. For example, the child may make a play in which “bad guys” steal gold from “good guys”, with a lot of (pretend) violent battles. The play themes are initiated by the child but the therapist helps the child manage his fears and hold the frame of pretend so that the child can create an elaborated representation of the fears. This capacity to actively create a representation in play of otherwise unimaginable frightening feelings can transform the child’s experience from helplessness to mastery. When this is accomplished, the child is not only free to let go of her poops, she is also free to move on with her development.
I want to add something about children with disturbed or uneven development, including but not only children on the autistic spectrum. These children often do not have the capacity to interpret signals from their bodies in an effective way. For example, often they do not “know” they are cold outdoors or do not feel the urge to urinate. These children are at special risk of getting constipated.
In my next blog I will address the issue of treatments for the anxious child that I promised to deal with at the end of that posting http://supportingchildcaregivers.com/2014/01/02/being-the-parent-of-an-anxious-child/.