How to Encourage Healthy Pooping Behavior in Kids

In most children, a behavioral strategy is needed in order to escape the cycle of chronic constipation, stool withholding, or poop accidents. 

Here are some examples of behavioral “challenges” around pooping:

1. My child is afraid to poop because it hurt her once. Now she holds it in.

2. My child is so busy playing and running around that he just doesn’t stop to think about the potty.

3. My child waits until the last possible moment and then it’s an emergency!

4. My child is in pain when pooping. Every time she feels it coming she gets scared!

5. My child doesn’t feel the poop coming at all so he has accidents in his underwear.

6. My child could play video games or watch TV all day long and not stop to use the bathroom.

7. Every time we travel, my child gets constipated.

8. My child pushes and strains so hard.

9. My child hides in a quiet place when working on a poop and often doesn’t want a diaper change.

10. My child hides his soiled underwear so I won’t find it.

Do any of these sound familiar? All of these situations deserve some careful thought. How do we parent through these moments? How do we curate an experience around toileting that is POSITIVE. How do we do this without messing up our child even more?

Your behavioral plan is going to make sure that you help steer your young child away from shame, fear, pain, control, apathy, inattention. It will help veer your family away from fights, power struggles, bribery, frustration, and hurtful words. Your behavioral plan is a moving target. As your child develops/matures, the behavior is certain to change with it.

We’ve previously discussed the importance of a good plumbing plan for the colon. When the colon is full of stool for long periods of time, it stops working well. To fix it, you have to keep the colon mostly empty. If you do that for long enough, the colon will heal. It will eventually start sending strong messages to the brain so that you “know” when it’s time to go. And, it will start to squeeze strongly in order to get poop out efficiently.

But, your plumbing plan is only 50% of the solution. Your behavioral plan is equally as important. 

I encourage you not to gloss over creating a rock solid behavioral plan. I say this because it is the number one pitfall to which my patients succumb. It’s tempting to just “get the poop flowing” and hope for the best. And in some cases, families will be lucky enough to get through it all without addressing behavior in some way. But most families will inevitably need to formulate a behavioral game plan of some sort.

And in case this point isn’t clear, we aren’t thinking about “bad behavior” that needs remediation. We are referring to age-appropriate behaviors that interfere with healthy pooping experiences. 

Here are the places to start when considering your behavior plan.

Is there fear of pooping?

If your child is afraid to poop or sit on the toilet, read all about fear and shame here. There may be fear from past trauma, like a hard/painful poop or being forced to have an enema. Sometimes the fear is more deep-seated. Just to summarize how fear can manifest in a young child:

1. Intense crying, irritability, or clinginess

2. The body getting stiff

3. Sitting on their butt or crossing their legs

4. Intense behavior or meltdowns when asked to use the toilet

5. Refusal to try to sit on the toilet

6. Crying while sitting on the toilet

7. Will pee in the toilet but insists on a diaper for poop

Fear has to go away before you can move forward with potty training. It’s a total non-starter. Remember that young children must take a leap of faith to feel OK relaxing their anal sphincter. You cannot force it or push them over the cliff. They have to be ready.

So if there is a trigger for fear (like using enemas, or forcing a child to sit on the toilet) remove it. If the poop is hard and causes pain, soften it with stool softeners (see our guide to osmotics here).

Does your child still use diapers? 

If your child is still in diapers (full time or part time), it’s important to ask yourself just how interested they are in using the potty. As outlined in our article on fear of pooping, if your child isn’t interested in the toilet, don’t force it. If your child is making it clear to you with words or actions that the potty is off limits, I strongly advise that you not fight this battle. 

First of all, you will lose this battle with your child. They hold all of the cards. If they don’t want to poop on the potty, they won’t.

Second of all, it will likely set back the time it takes you to finish potty training. If you are currently bribing, cajoling, or otherwise insisting on sitting on the potty, it’s wise that you pull back a bit. Trust me on this one. It’s adding gasoline to the fire.

Refusing a diaper change?

This is probably the one area that I think you can push back on. It’s not sanitary to sit in your own excrement for long periods of time. I think it’s OK to send the message that this is a line in the sand. It is OK after one or two warnings to inform your child that you are going to “do the diaper change for them”. And as parents, we know how to be forceful but gentle at the same time. Think about getting a screaming baby into a carseat. It MUST be done and we “make it happen” but we do it out of love.

Some Interest in the Potty?

If there is some (albeit tentative) interest in the trying the potty, you have to respect that fragile leap of faith that your child is trying to take. You don’t want to overplay this hand. 

Here’s the key to addressing varying levels of interest around the potty:

You want to show with your words and your actions that you, as the caregiver, really don’t care where your child poops.

You show your child that they are the decision maker on potty -vs- diapers. They get to hide in any corner of the house that they want to and grunt away without much intervention. YOU DON’T CARE!

Your child may bound with excitement to try the potty on one day and then sheepishly ask for a diaper the next. You are going to be TOTALLY FINE WITH THAT!

You care about art projects, jungle gyms, riding bikes, academics, and birthday parties! This is the stuff that childhoods are made of. Not pooping.

So, take that adult spotlight of yours and shine it elsewhere! With the spotlight off, your child will have the clearance to come test out the waters again.

.....Hopefully soon.

Wants To Try underwear?

With big kid undies comes big kid responsibilities

If your child has decided to wear “big kid undies” today, they should at least understand the following concept (using age-appropriate language, of course):

1. You get to choose a diaper or underwear today, but the ‘underwear’ choice comes with a special responsibility

2. If you are going to wear underwear, you have to at least TRY to use the potty. It’s the responsibility that comes with the wardrobe.

3. No one is expecting you to stay clean or dry! For goodness sakes! Soil a couple dozen Disney Princess undies for all we care. Practice is what matters. Because practice makes perfect.

So, my definition of “being in underwear” is not so much a matter of whether you are perfect at pooping in the toilet or not. My definition of being in underwear is someone who accepts the responsibility of trying to use the toilet to get rid of poop and pee. 

It is natural that some children will be in this “in between” space. They’re up for trying but things may not be going great. If you are in this category, you want to make sure that you are messaging “correctly” here. Assign no “good” or “bad” to underwear -vs- diapers or whether your child stays dry or not. It’s ALL GOOD.

Is your child exclusively in underwear?

If your “potty trained” child, in underwear has chronic constipation or encopresis, a strategy of scheduled trips to the toilet is BY FAR the most powerful technique to change the brain-gut connection.

I’d like to walk you through the general concept of scheduled toilet sits and then I will highlight why this is such a versatile tool for almost all young children. The protocol looks like this:

1. 3 scheduled trips to the toilet (one roughly after each meal)

2. Each trip to the bathroom can last for 5 minutes (or 10 minutes tops)

3. 21 sits per week (that’s just math, people!)

4. No distractions in the bathroom such as games, books, iPads.

5. Place feet on a stepstool to make sure that knees are above the hips (or use a small training potty on the floor so that the knees are bent)

6. Try a few deep breaths here and there

7. Don’t push to hard—just use the same pushing pressure that you would use to blow out birthday candles

8. Praise and possibly reward your child for the effort–just for trying to use the potty–not for pooping (see below)

On the one hand, it seems so simple! Just 15 minutes of potty time per day. But in this simplicity is some beautiful elegance. Let’s break down why this protocol works so well:

1. Ritual:

Young children are really terrible planners! For example, they might get the message that they have “to go”, but there are so many other distractions that compete for your child’s bandwidth. When you are four years old, how can you mindfully prioritize a trip to the bathroom over a TV show, the playground, or the swimming pool?

With the toilet sitting protocol, kids are told to stop what they are doing–to switch gears—and to try using the toilet. Repeating this ritual over and over changes the hardwiring. Ritual creates life long habits.

2. Meditation:

Sitting for five minutes can feel like a time out. But it’s really an exercise in HOW to effectively time out. Without outside distractions like electronics, children are more likely to focus on their own body. They will pick up on subtle body cues such as pressure and sounds. When you think about it, this is really a loose definition of a meditation. We know meditation can help strengthen connections between brain and body. And this is exactly what we are trying to achieve here.

3. Doesn’t rely on waiting for “the urge”:

If you suspect your child has a muted or absent signal when it’s time “to go”, you can’t expect your child to just go to the bathroom when the need arises. That’s the point. It need DOESN’T come up very often. So, scheduling multiple toilet sits spread throughout the day can really lead to productive output without waiting for an unreliable, unpredictable sensory system to kick in.

4. Leverages the natural body rhythm:

Sitting after meals has two benefits. First, there is the gastrocolic reflex that is triggered when your stomach starts to fill up with food. Once triggered, the reflex sends a message down to the colon. The message goes something like this:

“Make some room down there! We’ve got a new cheese burger coming down the pike!

This makes the colon start squeezing. So doing toilet sits after a meal increases the chances that you will catch a bowel movement on its way out!

The second benefit to sit after meals is that you already have built-in transition time.

You’ve got this captive audience that has already been corralled and seated at the table. use this momentum in your favor! For many families, it works best to have the following protocol: We eat, we take our plates to the sink, we use the bathroom, and then we are excused.

Some families will make a good argument to do their toilet sits at other, more convenient times. Use your best judgement here.

5. It helps the pelvic floor:

The most efficient toileting position is having your knees at the level of your hips or higher. This gets you into a squatting position. The squatting position opens up the bottom of your pelvis so that poop will come out easier.

It’s actually the position that humans were meant to use for pooping. Think: cave men. The modern adult toilet is really not ideal when it comes to pooping mechanics. Feet dangle off the edge of the toilet. The pelvis straightens out and closes off. Kids wiggle around to stay balanced. With the feet planted firmly on a stool and the pelvis bent, you can open things up quite a bit.

Praising and rewarding:

Let’s face it: Making a four year old sit on the potty 21 times per week on demand is really hard to do–like soul crushing–for some families. How do you convince a kid to do toilet sits? Do you explain that they are an investment in a healthier tomorrow and that it will make the problem go away?

You don’t. You can’t.

You bribe them. Well, sort of.

You incentivize for behaviors that you want to see more of. It’s like giving out a bonus to your employees at work. If they meet the company’s expectations, you give them extra money. It is a motivation tactic to get them to do their best.

The right behavior In the case of a toilet sitting ritual, the behavior we are looking for is ‘effort’. We want to see that our child is part of his/her own solution. We care that they are doing the practice and therapy needed to get better one day.

A toilet sitting ritual is not about the poop. If we praised and rewarded for pooping, we incentivizing something that your child doesn’t really control. What your child does control is behavior. Reward for them when they put in the effort. The right behavior is doing all your toilet sits for the day without complaining about it; without making a big fuss; without drama.

The right incentive

So what is a good reward? A good reward is not expensive and not luxurious. But it is definitely motivating. Like a Christmas bonus at work, the reward has to hurt a little bit if it is not earned.

So, a sample incentive scheme might look like this:

A sticker on the calendar for every day that the sits were done (without complaining).

7 consecutive days of stickers will earn you a trip out for ice cream, 30 minutes of screen time, or a trip to the dollar store.

You could even do a prize for one month of sitting. Just up the ante somehow. Every child has at least a couple of “weak spots” that you can exploit.

How to handle school

If your child goes to school there is typically not a lot of control over how your kid toilets. So the idea of doing arranging a reliable scheduled toilet sitting protocol is hard to imagine. I have both a hard line and a softer line to this problem. For the children who clearly need a more rigid structure, I tend to insist on a toilet sit after lunch. For children that don’t need so much structure in their life, you may be able to start with just a breakfast and dinner sit at home, leave the school out of it for now, and see how it goes.

• In pre-school, this would be a simple discussion with your child’s teachers. I coach parents to approach this discussion with a message akin to “how can we all work together to give our child a health experience around toileting”. Making sure that a teacher is reminding, encouraging, or escorting a child to the bathroom is acceptable in pre school.

• In grade school, things can get a bit harder. I recommend sitting down with your child’s guidance counselor, school nurse, or home room teacher (whoever appears to carry the most authority in matters such as this). You can have the same discussion about working together. And in most cases, this will be all you need to do. Some children will do their toilet sit in a bathroom near the classroom. Others can go to the school nurse’s office if need be. Usually school nurses will be OK with this as long as a protocol or system is in place. Occasionally, a school will require a note from a doctor. However this is not very common for young elementary school children (think K-2).