Dr. Sarah (00:02):

Ever wonder what psychologists moms talk about when we get together, whether we’re consulting one another about a challenging case or one of our own kids, or just leaning on each other when parenting feels hard, because trust me, even when we do this for a living, it’s still hard. Joining me each week in these special Thursday shows are two of my closest friends, both moms, both psychologists, they’re the people I call when I need a sounding board. These are our unfiltered answers to your parenting questions. We’re letting you in on the conversations the three of us usually have behind closed doors. This is Securely Attached: Beyond the Sessions. us usually have behind closed doors. This is securely attached beyond the sessions.

(00:41):

Hello. Welcome back to the Beyond the Session segment of the Securely Attached podcast. We are going to answer a listener question today, and we have Dr. Emily Upshur and Dr. Rebecca Hershberg here with us. Hello.

Dr. Emily (00:55):

Hi.

Dr. Rebecca (00:56):

Hello. Always such a pleasure.

Dr. Sarah (01:00):

I’m really excited about this question. Emily, you are going to be so happy because this is like…

Dr. Rebecca (01:07):

Oh, I’m so intrigued. She’s going to be happy and I’m not?

Dr. Sarah (01:11):

Well, it’s funny. I’ll, here’s the question. So this woman writes in, hi. First of all, I really enjoy listening to your podcast. It’s so pleasant to listen to you and your colleagues and I have really gained so much. Guys. We are doing a good job. She likes what we’re doing. Yay. I love her. I love her. She love, okay, sorry. She goes on. My question might seem medical in nature, but I can assure you I think I need guidance from a psychologist, not a medical doctor right now. My three-year-old daughter who has been toilet trained since November when she was two and a half, still refuses to poop in the toilet. She is terrified. She also believes she can’t, when she says she needs to poop and goes into the toilet, she jumps right off saying that she can’t. I have tried different laxatives as per doctor recommendation, but they only make the situation worse and say left terrible side effects. Any advice? Please, thank you so, so much. It would be a huge help to get some clarity here. The reason, first of all why I said Emily, you’re to love this question is because it’s kind of like a running joke at our practice that Emily has literally become our poop expert. We get a lot, surprisingly, we get a lot of referrals for parents with questions like this or parents having issues with late onset toilet regressions and pee and poop accidents and all these things, and Emily is like our poop whisperer.

Dr. Rebecca (02:38):

I love it. Emily, up your poop whisperer. So why don’t you jump in Emily and tell this mom what to do.

Dr. Emily (02:45):

Well, I love that this mom is thinking about the psychological side of this too. I do want to zoom out for one second and say it’s a little bit of both medical and psychological. So I want you to work as a team with your practitioner, your pediatrician or a gastroenterologist and a psychologist if you think there’s an angle for that, they tend to be really good at referring to us. And so it’s really nice to have that team-based approach to this because there does, as these patterns go on, there can be sort of more physiological or body related side effects, and so we want to work together on that. I think that’s really important to note. Even nutritionists are a good piece, a good part of this team just to put that out there. But the first step I always, always say for parents is to start tracking. I really want you to get a sense of when your child’s eating, moving and going to the bathroom. Those are typically what I want to get a sense of. And if they’re a child, this child might be in preschool or daycare or something that to get a sense from them as well because setting is also a really important piece of this. So that’s usually where I start. What about you guys?

Dr. Sarah (04:00):

Yeah, I do. Honestly, anytime there’s an issue with pee or poop related concerns that have been ongoing, I really do always encourage looping in pediatrics because, and not to be a broken record or echo exactly what you’re saying, but it’s usually both things interacting. There’s usually oftentimes it’s like, Ooh, there was about a constipation.

(04:31):

And it made one poop really painful, especially for very little kids. So it’s like this is all brand new to them and they have a one tough experience with a medically related possibly constipation episode that made it painful or uncomfortable or overstimulating in some way and now they’re wanting to avoid it. Or even if it’s not even a conscious avoidance, but a muscle memory, their body is now tight tensing up and clenching muscles and making it harder for the body to relax and release. So there’s a biological psychological feedback loop and behavioral loop that can just kind of get really self perpetuating somewhat quickly. So that I think is a very important point.

Dr. Rebecca (05:28):

Yeah, I start there. I am just thinking about doing an intake for this type of a case and I start absolutely looping in the pediatricians, finding out the history and how we’ve landed here. Also a really empathic and compassionate assessment of parent anxiety because I think that’s the other part of this loop that gets cycled in is that it’s so hard to see our kids, it sounds like less maybe in the family than I’ve seen in others, but where your child is really in pain going to the bathroom and that’s real, and then a pediatrician might say like, oh, it’s just psychological and you’re like, my child’s been riving and shrieking and of course parent anxiety. And then there’s a lot of pressure on how and when the child uses the potty, even parents with the best of intentions who are like, no, I promise I’m calm, I promise I’m calm. But you can just tell as they’re talking about it. And so really trying to just cool down the whole system around pottying and bowel movements and providing reassurance that this is common, this happens a lot. We will get through this. This is one moment in time I think is a really important piece to factor in as well.

Dr. Emily (06:48):

Yeah, that’s my other piece of the tracking. It’s not just tracking your child, it’s also tracking how you respond, how you show up. And what’s tricky about toilet training and that type of thing is there’s often multiple providers, and so that’s also something to the tracking helps you all get on sort of a same page. How are we each approaching this so that we can see if it’s really discrepant, if we need to work on alignment and messaging, cooling the whole system. Those are really important pieces of the first steps that I take for that.

Dr. Sarah (07:22):

Yeah, no, that’s interesting. And things to be looking for in the patterns as you’re tracking. Is the child able to go poop when they’re at school but not at home? Or are they comfortable going poop when they’re at grandma’s or are they okay going poop at your house with you? But if you are somewhere else with them, they don’t. So setting and individual supporter can be things to look for patterns around.

Dr. Emily (07:51):

Yeah, there’s also, as you were saying that there’s also like are we doing anything to sort of accommodate that? I have a lot of families that leave a pull-up on then depth and the child will only poop in the pull-up. So it’s not that they’re not doing it and it’s not regular, but it’s always in a pull-up and they sort of graduated from pull-ups and so what do we do? Or will they sit with them in the bathroom for an hour? There are some really important behaviors in the system that we want to be aware of and see. I’m not saying we have to eliminate all them, but we do want to know what they are so we can work on figuring out the meaning and if that’s something that’s reinforcing or making it more difficult to break that cycle.

Dr. Sarah (08:35):

Which makes me think of a very common therapy intervention for this type of situation, which is called space. We’ve talked about it a ton of times in the podcast. I’ll link some of the other episodes where space has come up in the show notes, but space stands for Supportive Parenting for Anxious Childhood Emotions, and it’s a very manualized treatment that helps a parent map out the ways that they are possibly accommodating or rescuing a child from an anxious feeling. So in this case, if there was anxiety about going poop in the toilet, the over accommodation behavior or the rescuing from the feeling would be, use your examples. We just put a pull up on then or iPad.

Dr. Rebecca (09:28):

We give, I was going to say we give an iPad, we watch YouTube videos. We have both parents come into the bathroom.

Dr. Emily (09:36):

We sit on the toilet for two hours. There’s a lot of too long.

Dr. Rebecca (09:43):

We read books about it all. Again, these things that start out, I mean the thing about accommodations is that they’re often insidious and a lot of times the hardest ones to break are the ones that start with the best event. It’s like we read books about, Ooh, great, that’s a great place to start, but then it crosses over into putting so much attention on it. So that’s when the kid gets one-on-one time. If the kid does something healthy in the bathroom, no one really pays attention. But if the kid does something that’s more problematic, suddenly they get to be late to school. It’s those sorts of things that we all fall into quite naturally and understandably and we have to bring attention to so that we can break probably not by any means causing the problem, but certainly perpetuating some of the patterns around it.

Dr. Emily (10:29):

Yes, I would also, I think this person’s child is three, and that can also be on the earlier side. I wouldn’t panic just because they attained the skill and then it sort of regressed it. There could be so many reasons for that regression, so we didn’t hear about that. But I’d also say taking a pause and sort of regrouping, and to Rebecca’s point, lowering the temperature and this child’s three and then trying again with a fresh slate is often I’ll get these referrals for older children. And that’s a little bit different than this particular listener’s question. This is a child who could have a fresh start and maybe just sort of cruise through in a different way.

Dr. Sarah (11:15):

Yeah, I was actually just thinking that too. I was like, we have to really anchor this particular child in their developmental timeline. And so yes, it is not uncommon at two and a half, three years old to see kids really starting the middle of the bell curve. Kids might be really starting to move into mastering pooping on the potty, but that’s not the whole population. It’s actually super, super developmentally typical for a three-year-old to have not yet gotten to this step of regularly being able to poop on the potty. So I also just want to, and again, when we talk about developmental milestones like this, I think it’s very important to have a little bit of data on your own child. If this is a kid who was out of diapers and peeing on the potty at two and a year later is still struggling with the poop stuff, that’s very different than a child. She was saying it’s been maybe five months, six months that this child started toilet training and it could take a while. I think we have these books. What is it?

Dr. Rebecca (12:43):

That’s what I was going to say that I

Dr. Sarah (12:45):

Done in three days. That’s not, that paints a very unrealistic picture of how this…

Dr. Rebecca (12:49):

That one, and there’s one that I actually, the one that a lot of people use is Oh Crap potty training I think. Oh Crap potty training. And there’s parts of it I really like. I don’t want to throw anybody under the bus. There’s parts of it I really like, but one part that I think can lead a lot of parents astray is that’s an incredibly rigid description of this idea of once you start, you can never stop. It’s incredibly damaging to stop and sometimes you have to stop. I mean, sometimes your kid gets sick or, and again, and looking at development as you said, like a child who’s two and a half who’s mastered potty training and then regresses at three. There can be a million reasons for that, but you need to understand the whole family. Was there a new baby? I see that all the time. So I just think…

Dr. Sarah (13:38):

Or even an illness just to name a couple very common things that can cause regressions in potty training. Yes, definitely new sibling move, new teacher at school medication. Again, a constipation episode that maybe went off under the radar that we didn’t realize was happening, but also getting sick anytime they have a fever.

Dr. Rebecca (14:01):

That’s what I said, they may have gotten sick. Absolutely. That was the first one I mentioned because I feel like that’s all, I mean, we had to stop with one of my sons. I remember also giving, we gave the pacifier back, which everybody says, don’t give the pacifier back ever once you take it away. He got the flu, he got the flu three days, took away the pacifier. Of course, we’re giving it back. And I just think looking at kids, not just where they’re developmentally, but what’s happening in this moment that maybe we just trust our instincts beyond some of this very rigid black or white doctrine.

Dr. Sarah (14:35):

But just to clarify what I meant, the difference, so when you’re saying if your kid is sick while you are doing this and you choose to stop, yes, makes so much sense and I think we want to give parents permission to be responsive to that in the moment. What I’m saying was actually more like sometimes we don’t realize if our kid has been showing steady signs of moving in the right direction with long-term potty learning, they’ve been doing it for a while and we’re good, and then they get sick, they have a fever, strep, the flu, something. We can see regression in certain milestone acquisition after that point and not always think to link it to that. That’s what I ended up being sick. So I mean there’s two different ways. Being sick could interrupt this process, but I want to just distinguish those two.

Dr. Emily (15:33):

Yeah, I mean the other one that I think is really important is each child is very different. And I remember the Oh crap book. I love that book. I thought it was really great, but I had children who could never do nighttime. They didn’t do nighttime forever, and there’s a lot of linking between day and night. So again, I think it’s like your muscle tone. There’s a lot of physiological, to my point in the beginning, there’s a lot of real medical overlap and overlay and sort of working. I often work with the pediatrician or with the gastroenterologist to see, or OTs and PTs to really see where there are some biofeedback. To your point, Sarah connections and how I can help give scaffolding, psychological scaffolding to help with that and meet the child where they are is really important.

Dr. Sarah (16:23):

So that actually might be a helpful direction to go in right now because I’m thinking too. Okay, so yes, mom, go check in with your pediatrician. Look into that piece or a GI, but let’s just say…

Dr. Rebecca (16:38):

Which it sounds like she did because she talked about how she got the laxatives from the pediatrician.

Dr. Sarah (16:43):

But now we’re at this place where we’re like, okay, but this is a kid who’s at three is jumping off the potty. Every time she sits down on it, she’s saying she can’t, she’s expressing fear and mom is saying that the things they’ve tried feel like they’ve made the situation worse, which might have compounded anxiety around this just because a bit of a spotlight got shown on it and it agitated the system that you’re working inside of right now. So from this point, what are some things, Emily, you were talking about this is where I might try some scaffolding once I’ve gotten this information, how do we help this child become less fearful and more relaxed, open, comfortable taking some risks in the bathroom?

Dr. Emily (17:37):

I always say my favorite thing to do is when you’re stuck, this is to not necessarily try to make it harder. So I might introduce some levity. I might be like, I might play music in the bathroom, or I might do something that this child knows to be silly or fun. I might do something a little bit exposure oriented. So I might have the child sit on the potty with their clothes on something that’s not scary, but a few times a day we play a sit on the potty game just to build up to decouple this. To your point, Sarah, clenching of muscles scared, sort of getting really tense when I’m in the bathroom. I think those are some of the first steps that I would always take. I think it becomes very granular in these situations. So if this child is only afraid of the plunk sound, then I think we work on some of that. But there is a lot of individualization of this, but I think that if I were to give a general rule, it would be can we be in the bathroom? Can we lower the temperature? Can we make it silly? Can we change the routine so that there isn’t as much pressure and there’s not as much coupling of like, and you’re in the bathroom and poop has to come out and it has to go on the toilet and then we’re out of here and it’s over. I think that that’s a really important place to start. Yeah.

Dr. Rebecca (19:03):

Yeah. I think the other thing that I often start with is can we go a few days or a week even without talking about this at all in our family, what would it look like? We and I often encourage telling the child, so it’s not just this weird shift that they don’t understand, but saying, we’ve been talking so much about pooping, there’s ways you are scared of using the pattern. We talk about it, we try to make whatever. We’ve been talking so much about it, I’m getting a little bored of talking about it. I want to talk about other more fun things. I want to do playful things. I want to enjoy our family. You’ll know when you need to poop. I’m here if you need me. Let’s just not talk about it. And I have seen that change everything that it turns out because parents will say, wait, not talk about it, not what if they don’t go?

(19:56):

What if they don’t? I’ve absolutely seen that just to be clear, not be effective. I’ve seen kids who need more, but so much this age where there’s the resistance or the anxiety is coupled with the age where there’s also just this need for control and this kind of pushing back or being scared of parents’ anxiety. There’s such high pressure. It’s like if you just, what would happen if you just told her, we’re going to take a break poop when you want to poop. Don’t poop when you don’t want to poop. Let us know if you want. Don’t let us know if you don’t want. And sometimes that really, really is helpful. And so again, I don’t want to say it’s always what I’d recommend. So much of this is about, as you said, noticing patterns in a family and assessing a particular child and where they’re at and what the journey is and whatnot. But I also just want to put it out there that sometimes just it’s become this focal point of a family. And when you just take that away in a very clear conscious way and parents can’t imagine, it’s like, wait, we’re going to leave the house without even suggesting that she use the pot. It really can do a lot.

Dr. Sarah (21:05):

And I would actually encourage that same break to be communicated to school or wherever else she’s at and be like, we are all going to take a collective break from talking about it and then see, just be observant what happens over that week that we’re not talking about it. And it’s a lot about tuning into your kids’ cues. I think, to your point, Rebecca, sometimes that not talking about it doesn’t change their signals to you that they’re anxious around this. And sometimes they will literally show you how calm that makes them and their curiosity starts to come back online and their ability to kind of explore that space again comes back online. And if you see that you can follow it, right? There’s no rule as to when you should start up again. And at three, I would say you could take more than a week. I would give it a little longer too, because there’s no rush right now developmentally, there’s really no rush. There’s no window that is closing anytime soon for this kid to learn this on their own and still be well within the typical range of mastering this skill. So lower the pressure reset, follow their lead when she is kind of interested again, or if you’re feeling like there’s still a lot of anxiety around it, then start to do some of these exposures like Emily’s talking about, of reintroducing bathroom time after this break with, again, still no focus on pooping, but just being in the bathroom, having a dance party in the bathroom, sitting on the potty with our clothes on and playing a quick game or reading a book or singing a song and then leaving the bathroom and increasingly moving more and more up towards it.

(23:14):

And I think that would be helpful. Also, one other thing really quick that I like to help kids start to practice when they’re dealing with potty learning at all, and I think we had talked about this in another episode about potty training, which we can link, but is helping them with their interceptive awareness. So interception is noticing our cues that are coming from inside our body. So like the sensation of being hungry or the sensation of being thirsty or the sensation of having to pee or poop, right? Those are interceptive sensory inputs. And so again, not related to the pee and the poop, I don’t start there, but helping kids start to learn about and notice when they feel hungry or thirsty, what do those sensations feel like in their body? Building that awareness, building that language around that, and then starting to expand that to include urgency, feelings around using the toilet.

(24:19):

And then we can leverage that kind of sensory awareness to help them get better at going to the bathroom, listening to their body, having fewer accidents like building in time and a routine around. When I feel that feeling, I stop. I go and I sit and I relax my body and let whatever needs to come out, come out. And then you can go back to my, I can wash my hands and go back to my play. That there’s some of that comes from building that sensory awareness piece too, which we didn’t talk about, but I think is helpful. Any other thoughts? I feel like we really got into all layers of the poop.

Dr. Emily (25:03):

Yeah, I like it.

Dr. Sarah (25:06):

All right. Well, I will see you guys very soon. Thank you for sending in your questions. We love them. Keep them coming and we’ll talk soon.

(25:13):

Thank you so much for listening. As you can hear, parenting is not one size fits all. It’s nuanced and it’s complicated. So I really hope that this series where we’re answering your questions really helps you to cut through some of the noise and find out what works best for you and your unique child. If you have a burning parenting question, something you’re struggling to navigate or a topic you really want us to shed light on or share research about, we want to know, go to drsarahbren.com/question to send in anything that you want, Rebecca, Emily, and me to answer in Securely Attached: Beyond the Sessions. That’s drsarahbren.com/question. And check back for a brand new securely attached next Tuesday. And until then, don’t be a stranger.