SARAH O'DOHERTYanswers readers' questions
Q
I have a 19-month-old niece who seems to get very upset when she has to defecate. Her GP had diagnosed a fissure and prescribed a regular osmotic laxative (lactulose) to keep her stools soft. Unfortunately, now every time she defecates she pulls her knee up towards herself, and looks to her parents for comfort. They then have to provide some sort of distraction to keep her calm. She does have occasional nappy rashes but we are worried that she may develop a psychological fear of going to the toilet.
A
THIS IS an interesting question. It raises a number of issues, and shows that even the most well-intentioned of parents can unconsciously play a part in establishing and maintaining unwanted behaviours in children.
It is very common for minor behavioural issues to follow when a child has been sick. The normal rules and regulations can go out the window when parents are stressed and worried about a sick child, and it can take a bit of tweaking to get things back to normal.
Your niece had an anal fissure (a small tear). The literature says that this can be painful, especially during a bowel motion, but it usually heals within about two weeks.
The issue here is that, despite the fact that she is most likely healed and no longer in pain, she is still upset, worried, and expecting comfort and attention every time she has a bowel motion. She has learned to associate a certain bodily sensation with an emotional reaction and subsequent series of events. However, the behaviour is not one-sided, and her parents play their role in the routine by automatically providing attention and entertainment. It’s important to remember the mantra that “any attention, good or bad, can help maintain a behaviour”. In this situation, your niece is getting lots of attention.
As a first step, her parents need to be completely sure that she is not in any physical pain. A return visit to the GP will clear this up. Nobody wants their baby – who can’t vocalise how they feel – to be in actual pain without providing comfort. A child should grow up feeling secure and knowing that if they look for help, they can get it. However, this has to be balanced with the need for a child to learn to “self-soothe” and manage minor distress by themselves. Being certain that she is no longer in pain will give them the confidence to manage this situation more decisively.
At the moment, when she starts a bowel motion, she probably sees two anxious faces looking back at her. Babies and toddlers look to adults when gauging their own reactions to situations. She picks up on their worry and concern, which in turn heightens her own anxiety.
Her parents were absolutely right to use distraction at the start; it works well and is used in hospitals and homes all over the world to take a child’s mind off something painful. But, distraction is only really a short-
term measure as it’s very labour intensive. At a more psychological level – and this is where your concerns come in – it is not good to create a long-term link between the natural everyday habit of toileting and the emotional reaction of anxiety. She will probably start toilet-training soon, so it’s a good plan to get this cleared up and out of the way to avoid any potential complications.
The key to changing a behaviour like this is to undo the automatic associations that have built up between the act (toileting) and the outcomes (worry from parents, distractions, lots of attention). Changes can be introduced gradually over a period of weeks so that your niece, and her parents, can slowly get used to the new routine.
Her parents should start by creating a relaxed, calm atmosphere around toileting. They should use a soothing voice, smiles, laughter, and give her the same attention as they would when she is going about any other daily activity such as feeding, playing or bathing. The message they want to give is “well done, but we are not worried, and this is not a big deal for us or for you”. They can gradually tone down the level and time of distraction.
Change will not happen overnight, and she will probably keep going with her old behaviour for a while. There may be a few tears and tantrums as she adjusts to the new reaction from her parents. They in turn should not see this as a sign of failure, but as normal and natural in the context of the changes they are introducing.
If the wider family is involved in her care, it is important that her parents decide on a single consistent strategy and share it with all her caregivers so that she doesn’t get confused by different responses. If even one person rewards the behaviour or uses a different approach, it can drag things out. (Different approaches to managing a child’s behaviour is an age-old source of tension between parents, grand-parents, and other family members.)
If you’re a family that discusses these things openly, it is worth remembering that children become more aware of their own toileting habits as they mature, and can become embarrassed and self-conscious if they hear their routines or failings being talked about by adults. With this in mind, it might be good to start getting into the habit of discussing these important issues out of her earshot.
Dr Sarah O'Doherty is a clinical neuropsychologist.
Dr John Sharry is on leave.
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