Did you ever complain to your parents of a stomach ache when you were a kid? It’s what I call an “insert standard parent line here” moment. An “insert standard parent line here” moment is when a child says or does certain things, all parents answer the same way. For example, when a child says, “Bobby’s mom says he can go to the playground.” the standard parenting line is, “Well, I’m not Bobby’s mother.” When a child says, “She told me to take the candy!” the standard parenting line is, “If she told you to jump off a cliff, would you do it?” One explanation for these baffling truths might be that standard parenting responses are good, common sense, responses to common childhood excuses, attempts at persuasion, and just old-fashioned trying to get away with something.
The standard parent answer to a child’s complaint of, “Dad my stomach hurts” is, “Do you have to go to the bathroom?” As a parent, I think a complaint by my kid of an ache or a pain is one of the most difficult parenting dilemmas. When one of my kids complained of a stomach ache, many things went through my brain simultaneously. “He is faking.” “She snuck a bunch of candy while I was on the phone.” “Did I cook that chicken well enough?” “The pizza from last week may not have been the best dinner option, but it smelled fine and my stomach doesn’t hurt.” My brain also immediately starts ticking through our schedule to see if there might be something he or she is anxious about attending or simply trying to get out of. It’s a fine line between believing my kid and remembering that I had run the thermometer under the warm water when I was a kid!
It turns out, however, parents are right to wonder if a stomach ache may be caused by needing to go “to the bathroom.” Let’s face it, our parents weren’t asking if we had to urinate. They were asking if we had to “have a bowel movement.” Kids tend to freak out if their parents are constantly asking them about their bathroom habits. As a parent, it is difficult to know if and when you should be asking. Hopefully, this post will help parents determine if there is a chronic problem that should be addressed with a medical professional.
The medical term for an Elimination Disorder With (having bowel movement accidents outside of the toilet) or Without (no accidents) Overflow Incontinence is Encopresis. I will focus on chronic constipation without accidents because many kids don’t reach the point where they have accidents, yet chronic constipation may be causing some type of difficulty either for the parent(s) or the child. If a child is having accidents outside of the toilet and the child is at an age when accidents would not be expected, seek a physician’s advice. No medical treatment of constipation will be discussed. I am not a medical doctor.
My knowledge of everything I am about to discuss came either directly or indirectly (insights gained in my own practice) from Edward R. Christophersen, Ph.D.. I have credited Dr. Christophersen before in my blog. He was and is one of my mentors, especially when it pertains to kids and constipation. Dr. Christophersen has published scholarly articles and has traveled the country speaking to pediatricians about constipated kids. As I understand it, he became an expert out of necessity. Dr. Christophersen figured out how to treat kids with chronic constipation because physicians sent kids who were having bowel movements outside of the toilet to him. It was, and sometimes still is, believed that toileting accidents where a symptom of some type of psychological disturbance.
When a person is beyond the age when it is culturally or socially appropriate to be having bowel movement accidents in ones pants/diaper, many believe the accidents are due to a psychological issue. Theories have included children having accidents suffer from psychosis, or that having accidents is an indicator of future psychosis. Psychosis is extremely rare in children and the answer is much less dramatic. Bowel movement accidents outside of the toilet can be a biological reaction to a child’s behavior and environment. The child may have also suffered some type of trauma, but the two are separate.
Some of the following information is anecdotal, meaning it is through my own observations. I have not published this information in any professional journal and I have not conducted double-blind research concerning constipation in children. If after reading this post you wonder if your child is chronically constipated, discuss it with a qualified medical professional. Why am I discussing chronic constipation? Because kids who are chronically constipated continue to end up in my office usually for other, sometimes significant, behavior problems.
Please don’t be offended by me calling it poop. Most families and kids call it poop. Other names I have heard are “boom boom,” “going number 2,” and “poopy.” Some simply go old school and everyone knows that if a family member says “I have to go to the bathroom, or do you have to go to the bathroom?” there is a mutual understanding it means poop. I will try and walk the fine line between professionalism and practical parenting. It took seeing hundreds of families for me to see and believe there is a connection between chronic constipation and behavior. No wonder parents are left wondering about toileting accidents. Some parents have been punitive with their child who has had accidents and have openly wept in my office when we discuss chronic constipation. Parents gain an understanding that their child is not only NOT having accidents on purpose but many times their child can not help having accidents.
How Does a Parent Know if Their Child is Constipated?
The definition of constipation is confusing for parents for a variety of reasons. When kids reach a certain age, different for each individual kid, and they can wipe themselves after going to the bathroom, parents stop asking questions and/or looking at bathroom results. In fact, many of us are so happy that our kids have reached the bathroom stage of independence that we never discuss it again. Kids also reach a developmental level where going to the bathroom becomes private. Sometimes kids are embarrassed when they are asked about going to the bathroom, while some kids have no trouble discussing their bathroom habits….in public or anywhere else!
There is no correct answer for how often a kid should have a bowel movement and many parents don’t know how often their child has one. If a child is not having a bowel movement everyday, I ask the child if it ever hurts when they go poop. If they say “yes” or “sometimes,” I get suspicious that they may have at least some times when they are constipated. If the parent and/or child tells me their child clogged the stool or were ever shocked by how much poop there was in the toilet, it is another clue that the child has had at least one episode of significant constipation. I have had countless parents say “no” when I ask about constipation. When I ask their child questions, the child’s answers are sometimes different.
Why don’t or won’t we talk about going to the bathroom? For the same reason it was really scary for me to write this post. Culturally, too much thinking or talking about bathroom issues is frowned upon. For parents, especially parents trying to figure out their kids’ behavior problems including, but not limited to, anxiety, night-waking, and eating problems, it is essential to discuss how their children’s bodies are functioning as a whole.
Encopresis without Accidents: A Case Example
Years ago, I saw a four-year-old girl, who I will call June, who was constantly thirsty. She was drinking significant amounts of almond milk and would throw long temper tantrums if she could not have frozen ice pops throughout the day. The whole family was not sleeping. She was small for her age. She often would refuse to eat. She also had a very limited diet. Her parents reported no history of constipation either to me or her physician. Her parents were diligent, caring, parents who just wanted answers for her negative behavior. Weeks later, June was hospitalized due to dehydration and constipation. This little girl taught me so much about what nuances to ask parents about regarding early warning signs, symptoms, and the progression of chronic constipation. This is one child’s story, however, and is not a scientific study.
Before going into the hospital, June had dark circles under her eyes and a yellowish-green color to her skin. Both of these symptoms could indicate medical conditions and she was under the close care of a physician. June received a week of IV fluids to correct the dehydration and the constipation was resolved. When I saw her weeks later, she had pink cheeks, bright eyes, and played contently the entire hour. She seemed like a different child.
June also had a history of eating problems. She would go days and even weeks without eating much, followed by days of eating significantly more than usual. She was extremely picky about what she ate and preferred bland food such as pasta, fish-shaped crackers, rice, bread, some fruit and fruit-shaped snacks. The only meat she would eat was chicken nuggets; from a restaurant that made chicken nuggets famous. She only finished small amounts of food, but seemed hungry soon after and then refused when food was re-offered. June’s eating behavior was being carefully monitored by her physician, so it was NOT why I was seeing her. I was seeing her for her extreme temper tantrums. Before June went into the hospital, her physician was working with June’s parents on normalizing June’s diet, increasing intake and the nutritional value of her food, and on getting her to gain weight.
Because June was treated in the hospital for dehydration and constipation, it made me start asking other parents about liquid intake. I found out that June’s case was significant and that most kids who were chronically constipated were not nearly as thirsty as June had been before going into the hospital. However, a natural biological response to something blocking the digestive system (poop) would be to move liquid from anywhere in the body to the block in order to get it to move through and out of the system. Even though June was drinking a lot of liquid, it seems her body could not get enough to both keep her from dehydration and clear the block. It’s important to keep in mind that extreme thirst can be a sign of other medical conditions. Talk to your child’s doctor if you are concerned about thirst and amount and type of liquid intake.
If you have ever seen an adult that has been up all night or gotten a terrible night’s sleep, you know that they tend to look physically distressed. They may be disheveled, irritable, in need of caffeine, have dark circles under their eyes, and feel “terrible.” Before she went into the hospital, June’s whole family was not sleeping every night. She was awake for hours and could not be consoled. Her parents were exhausted and looking to me for answers that would help the extreme tantrums, demanding demeanor, and lack of sleep and appetite. In the weeks that followed her hospitalization, the entire family was sleeping. June and her parents looked refreshed and happy.
Behavior Clues to Chronic Constipation
Appetite and what kids will and won’t eat may be a clue to whether or not a child is chronically constipated. When parents tell me their child will not eat much for days followed by days when they could not get the child enough food, I started asking parents if there was a bowel movement in between. Sometimes, there were stool-clogging, large bowel movements in between fasting and feasting. I started to see a pattern. Chronically constipated kids often only wanted to eat foods that are soft or that will turn soft once eaten. Maybe it is because crackers turn to mush inside the gut and will “fit” more comfortably if a child’s colon already contains large amounts of stool. A piece of steak, on the other hand, takes up more room than a full colon has to offer.
Many parents don’t know if their child has gone long lengths of time without having a bowel movement. Children don’t think to tell their parents it has been a week since they pooped. The back door to my office is adjacent to an alley and public parking lot. The alley also contains organic recycling receptacles for a bagel shop nearby. When the temperature was above 90 degrees recently, it did not smell pleasant and there were many insects working diligently to get to the rotting food needing to be collected. I parked in front so I did not have to go near it. It makes sense that organic waste, collected over days and even weeks in a dark, warm, belly creates the perfect environment for gas, odor, and swampiness that would not lead to overall health and wellness.
What children are drinking and eating may also provide clues. Drinking a lot of milk or consuming a lot of dairy, especially out of a cup with a lid, can slow motility and lead to constipation in some people. When kids drink out of lidded cups, they tend to drink more because they can carry a lidded cup around without spilling and lounge while drinking! Using water instead of milk in a lidded cup helps increase water intake which is a great way to combat constipation. Calcium is necessary for healthy development. Talk to a physician if you are wondering about your child’s balance of milk, water, and other liquids.
Diets high in simple carbohydrates like crackers, baked goods, sugary cereals, white pasta (yes, mac and cheese), and white bread all slow motility in the gut because they are low in fiber. Conversely, the things that are often hard to get kids to eat are high in fiber like raw fruit and vegetables, high fiber-focused cereal/crackers, beans, and dried prunes/prune juice. A well balanced diet of fiber, complex carbohydrates, and proteins at each meal and snack should be the goal for all of us rather than only pumping up the fiber at one meal, such as breakfast, with a simple carbohydrate, high-fiber, cereal bar.
I realize “selective” eaters make getting a well balanced diet a challenge for parents. I am always amazed when parents tell me their kids will eat anything. If a child is prone to constipation, and most kids who are chronically constipated have a least one family member who also struggles with constipation, it is worth investigating and rehabbing everyone’s diet with the help of a medical professional or nutrition specialist. The fiber content of common foods can easily be found online. Nutritional guidelines vary by age and kid, so also talk to a qualified professional about recommendations for how much fiber your child should get and nutritional needs in general.
It is developmentally typical for kids to avoid pain. If a child gets constipated and has even one painful episode on the toilet, some kids will try and “hold it” to avoid any further pain. They are not being stubborn. They are not being defiant. They are being smart. Unfortunately, “holding it” can set up a cycle of constipation where a very large volume of stool is able to be held. Another clue a child is “holding it” is if you have EVER said to yourself as a parent, “How did that come out of you?” Emphasis on ever because sometimes it only has to happen once to stretch the colon enough so that the colon can hold more stool than is typical.
Most people have never thought about what happens when your colon gets stretched out (I hope). It is not like a python who moves a rat or other large animal through the digestive tract and afterward, the python is virtually the same size in diameter. Dr. Christophersen described it like being eight months pregnant and wanting six-pack abs. Logically, six-pack abs can’t happen until the baby is born. Furthermore, once the baby is born, one must remain pregnancy-free to be able to achieve a “six-pack.”
Anyone who has ever been pregnant can tell you that the stomach muscles do not just snap back into place. After pregnancy, the stomach muscles just lay there flaccid (limp) for what seems like an eternity for some of us! The same is true for the colon. Once the colon has been stretched by large volumes of stool, it does not just snap back into place. It lays there. It lays there with the capacity to fill back up to its largest previous diameter. This process of “Whoa, are you kidding me!” about what is seen in the toilet, the child “holding it” so it doesn’t hurt when they go, and then a slow colon overfill gets repeated over and over.
Changing the cycle above can be achieved by increasing comfort for the child so they are not afraid to go and, therefore, stool withholding stops. When a child is not afraid it will hurt, and isn’t holding stool, then the colon muscle is able to heal. Unfortunately, one large bowel movement is like reactivating and re-injuring a chronic sports injury in the colon “muscle” and the process goes back to step one.
Kids don’t know that they are doing it, but holding in poop sometimes becomes a habit. When the colon is stretched beyond what is typical for months and years, it takes months and, sometimes, years to reverse the process. Diet, exercise, and great sleep are all part of helping the body heal.
Sometimes, the colon is overfilled and a child who is use to holding bowel movements successfully, can’t. If a child is exercising including playing in a park, swimming, walking or running more than usual, they sometimes have accidents. Sometimes the accidents can actually be diarrhea, even though the child is chronically constipated. Paradoxical diarrhea should be explained by a medical professional, so ask your child’s doctor if diarrhea is occurring when chronic constipation is also suspected.
Sometimes, the colon is overfilled and a child who is use to holding bowel movements successfully, is really successful. Have you ever traveled with a child who is prone to constipation? Traveling typically involves inactivity for long periods of time, making it very likely a chronically constipated child’s colon is filling up to its largest previous diameter and possibly larger. Parental diligence to a child’s diet while traveling often slacks off. “We are on vacation! Let the kid be a kid!” “Relax!” Absolutely! With a chronically constipated kid, however, it can set them back to square one.
A psychiatrist once told me that if a child wakes in the night, and they snore or drool, it is most likely due to tonsils and/or adenoids. Makes sense. Unfortunately, I have seen and continue to see a lot of kids who do not snore or drool, but are waking up at least once, sometimes multiple times at night. These families come to me to solve the problem. The sleep problem. It wasn’t until I saw an 11-year-old boy with a known history of constipation, nighttime and daytime anxiety, who was waking many times a night and NOT going in to wake his parents, that I realized behavior and constipation may be related even in older kids.
Independent of my work with the anxiety, he, like June, ended up in the hospital with severe dehydration and constipation. The hospital did what hospitals do to alleviate constipation and he saw me the next week. After months of making little to no progress with his night-waking or his night and daytime anxiety, all of his nighttime problems with waking and anxiety had gone away. His anxiety during the day had also significantly improved.
A possible explanation for night-waking being related to chronic constipation is that if a body has developed a habit of “holding it” while awake, the muscles used to “hold it” during the day would relax at night while the child is sleeping. If the muscles in the colon relax at night and the “block” starts to move through, it may cause pain and disrupt sleep by waking the child.
Sudden Onset of Other Behavior Symptoms
If a typically happy kid, with no trauma or significant life changes (even positive changes), no new or changes in medication(s), no prior anxiety, depression, school refusal, or any other behavior that appears suddenly, it makes sense to do a quick evaluation for chronic constipation. Constipation may not have anything to do with the sudden behavior problems, but it is always worth checking using the suggested questions and areas of development I have discussed above.
If you suspect your child may be chronically constipated, a medical professional should be consulted to help:
1. Make going to the bathroom comfortable.
- Keep the bowel working well by not overfilling.
- Monitoring diet and fluid intake.
- Encouraging regular exercise.
- Monitoring sleep.
If one or more of the above are not considered or monitored, chronic constipation can be a very frustrating parenting issue to solve. Kids won’t usually say, “Mother and Father, I am constipated. Will you please help me?” Instead, kids tend to indicate there is a problem within their body through their behavior.