Anal retentive is a term that’s fallen into disuse when it comes to the bowels, but the problem hasn’t gone away. Sigmund Freud coined it, and psychiatrists in the 1950s co-opted it to describe a pattern among low-IQ patients in mental institutions who pooped in inappropriate places.
Now known as “functional constipation,” the problem is alive and plaguing parents whose children, for various reasons, don’t want to do their business in a toilet.
The afflicted child may retain a bowel movement for days on end, resulting in soiled underpants, or feces excreted in public places.
Worse for the parents, there’s been no place to turn for help unless you’ve been lucky enough to know about Dr. Tom DuHamel, a Seattle-based child psychologist, and the only specialist in North America who treats the problem.
“Parents get frustrated,” DuHamel said on the phone last week. “They go looking for someone. Doctors say, ‘Well, your child must have a severe emotional problem, or they’re in conflict with you, or they’re trying to control you.’ ” Not so, he says. “These children are perfectly normal in all respects with this one exception.”
As he explains in his new book, The Ins and Outs of Poop: A Guide to Treating Childhood Constipation, the problem likely developed when a bowel movement was painful. The child associated the pain with sitting on the toilet and began to fear the routine. In one case, a boy confessed that he stopped sitting on the toilet after he saw a TV commercial in which a monster came from the bowl. This child held his bowel movements for as many as 10 days, then found a corner of the house where he felt it was safe to go.
“Remember that your child’s fear is irrational, like a phobia,” writes DuHamel. “The fear is always present no matter where he goes, but it is not as strong outside the bathroom as it is inside the bathroom. As with a spider phobia, the fear is greatest in the presence of a spider but less if you only see a picture of a spider. It is easier for your child to relax his poop muscles if he is away from the toilet.”
In other cases, functional constipation develops when the child is hyper-focused on a computer game and ignores the need to go to the bathroom. “The more they do this, the more their stool dries and hardens, making it more difficult for them to have a bowel movement when they do decide to go.”
On the phone, DuHamel explains. “For children who’ve developed the habit of withholding, the rectum distends and is stretched, and is not sending signals to them of urgency.” This is why one woman’s daughter pooed in the play area of an Ikea store. Typically when a parent consults a doctor, they advise, “Take a laxative. Increase your fibre. Everything will be fine.” But that’s not the case, says DuHamel. Seeing a general physician often “winds up being a big waste of time. I see many, many families who have gone that circuit.”
In his book, he advises parents to “clean out” the child with an enema, and then start a long-term regimen of laxatives. “DO NOT STOP THE LAXATIVE TOO SOON,” he writes in capital letters. “The goal for your child is at least three months of daily, soft poops with no recurrence of withholding.”
Set a time when the child sits on the toilet, and offer to be in the bathroom for support. “A morning BM is ideal but it’s not normal in our society, I’m afraid. Most kids are on an afternoon schedule, or after dinner. In the mornings, parents are going off to work. Nobody is going to be relaxed at that point when the clock is ticking. The goal is a medium to large stool every day, soft but not watery.”
DuHamel recommends using polyethylene glycol-based laxatives such as Miralax and Powderlax, as opposed to senna-based laxatives like Ex-Lax, because they soften dry stools more quickly. Either way, it’s a myth that long-term use of laxatives is harmful. “There was one study done 40 years ago that this could cause dependency, if you took them for too long,” he says. “But that study has never been replicated. I believe it’s a myth that’s been perpetuated.”