Autism and Stool Withholding or Fear of Pooping

Fear of pooping on the toilet, constipation, and encopresis are some of the most common challenges that parents of children with autism face.  Studies indicate that up to 30% of children within the autism spectrum will encounter these or similar bowel problems at some point. Though these experiences do not last forever, they can certainly feel like they will when a family is in the midst of dealing with poop issues.

I’ve been through this twice and worked with many families that experienced stool or bowel withholding and while there is certainly no one size fits all easy solutions, there are some things that are often helpful. In this blog, let’s delve into some of the reasons why children with autism may experience stool toileting refusal and explore some practical tips.

Constipation as a Cause of Autism Stool Withholding

Before taking any other steps, it is crucial to determine if your child is dealing with constipation and prioritize addressing this issue. Constipation is a common problem for children with autism, even when typical signs may not be evident. Frequently, when families express concern about diarrhea or observe small, runny stools in underwear between toileting sessions, it is, in fact, a manifestation of constipation known as encopresis.

Having encountered this issue in my own home, I understand the frustration it brings to the toilet training process. Seeking advice from a pediatrician is essential. They can evaluate whether your child is constipated and devise a plan to tackle this issue, enabling you to

initiate efforts to have your child successfully engage in bowel movements in the toilet.

It is also important to take into account food sensitivities and allergies, which are more prevalent in children with autism and can contribute to digestive challenges. Consulting with healthcare professionals and incorporating dietary adjustments tailored to your child's needs will play a significant role in addressing these issues effectively.

Once constipation and encopresis have been addressed you can begin tackling getting your child to consistently poop in the toilet. The first step is understanding why bowel issues are so prevalent in autistic children.

Restricted Diets

Nearly anyone that knows or works with an autistic child will recognize the struggle of getting them to eat a balanced diet. For many reasons, having a restricted diet is one of the biggest factors that contributes to toileting issues in children with autism.

Many children with autism do not care for fruits or vegetables due to the inconsistent nature of these foods. Unfortunately, this can lead to lack of fiber in the diet, which is a major contributor to constipation.

Inconsistent eating patterns also contribute. Many autistic children swing between periods of voracious appetite and phases of limited food intake. This erratic pattern can disrupt the digestive process, affecting bowel regularity.

Lastly, many autistic children do not like to drink water. Hydration is critical to having healthy bowel movements and so this often-exacerbating digestive issues.

Tips for Addressing Restricted Eating

1. Experiment with Smoothies: If you have a child that will drink milk shakes gradually expand this by moving to get them to drink fruit smoothies. Initially make the fruit smoothie fairly sweet and similar to a milk shake but gradually bits of vegetables can be added to the smoothie such as small amounts of spinach.

2. Whole Grain Snacks: Experiment with replacing some of the regular snack with a whole grain alternatives like bread or crackers. I personally have a son that has gone through seasons of only eating toasted bread and saltine crackers. He has made the successful transition to whole grain bread and whole wheat crackers, though, it did not happen overnight.

3. Granola bars: If you have a child that likes candy bars experiment with getting them to try different granola bars that contain oats, nuts, or other fiber filled foods.

4. Water Flavorings: Enhance water appeal by experimenting with water enhancers in the form of drops or powders. We had success by taking my son to the grocery store occasionally and letting him peruse all the water enhancers to pick one that looked appealing. With enhancers he is now drinking much more water, and although, I would prefer he drank plain water, I feel that the addition of the water in his diet is worth it.

5. Hydration Apps or Timers: Use technology to establish a consistent water-drinking routine through hydration apps or timed reminders. Many children with autism are extreme rule followers and if given a rule about following a schedules to drink a small amount, do quite well.

6. Fun Water Bottles: Invest in colorful or character-themed water bottles to make hydration visually engaging for the child.

7. Frozen Fruit Popsicles: Create homemade popsicles using pureed fruits and juice, or water for a refreshing treat that increases fluid intake.

Every child is unique, with individual preferences and sensory sensitivities. When implementing dietary changes, consider the child's likes and dislikes, as well as any sensory aversions they may have. Consistency, creativity, and patience are paramount in gradually introducing and adapting these strategies to align with the child's specific needs. If not progress is made after a time it may be worth asking your pediatrician for a referral to an OT or speech therapist for feeding therapy.

Fear of Novel Experiences and Rigidity

The fear of novel experiences poses a significant challenge in the toilet training journey for children with autism. This fear can manifest in resistance to using a new or different bathroom, creating a cycle where children "hold it in," leading to difficult-to-pass and painful stools, ultimately intensifying their fear of pooping. Also, the transition from diapers to the toilet represents a novel and, for many children, an unsettling experience. The change in sensation and routine can prompt resistance, leading to a pattern of holding in stools.

Practical Strategies for Overcoming Fear:

1. Social Stories: Utilize social stories to help children with autism navigate and understand the process of using the toilet. These visual narratives can introduce the concept of the toilet in a comforting and familiar way, reducing anxiety associated with novel experiences. If you are interested in reading more about using social skill stories with autistic children click here

2. Gradual Exposure: Gradually expose the child to the new or different bathroom environment. Begin with brief visits and positive reinforcement, slowly increasing the time spent in the space. This incremental approach allows the child to acclimate at their own pace, fostering a sense of familiarity and comfort.

3. Patience: Exercise patience throughout the toilet training process. Understand that overcoming the fear of novel experiences takes time, and progress may be incremental. Provide positive reinforcement and celebrate small victories to encourage a positive association with the toilet.

Navigating the fear of novel experiences in toilet training demands a combination of understanding, empathy, and practical strategies. By incorporating social stories, gradual exposure, and patience into the approach, parents can help children with autism overcome their fears and establish a positive relationship with the toilet.

As with any aspect of parenting, adapting strategies to the unique needs of the individual child is key, reinforcing a supportive and tailored approach.

Sensory Challenges in Bowel Training Children with Autism

Understanding sensory issues is paramount when addressing the complexities of toilet training for children with autism. Sensory sensitivities can significantly contribute to the withholding of poop, creating unique challenges that require a thoughtful and tailored approach.

Children with autism often experience sensory sensitivities that can impact their ability to engage in toileting activities. The discomfort or aversion to specific sensory stimuli may lead to withholding poop, as the child tries to manage or avoid the sensory challenges associated with the toilet environment.

Interoception, or the sense of the body's internal state, plays a crucial role in recognizing when the bowel is full. Some children with autism may struggle with interoceptive awareness, making it challenging for them to recognize the signals indicating a full bowel. This lack of awareness can contribute to difficulties in timely toileting.

Practical Advice for Addressing Sensory

1. Relaxation Strategies: While the child is sitting on the toilet experiment to find activities that they will find relaxing. Blowing bubbles can be a soothing and engaging activity, providing a calming distraction during bathroom visits or popping bubble wrap.
   

2. Digital Distraction: Use digital devices as a source of distraction. Allowing the child to watch a preferred show on a phone or tablet can divert their attention, creating a more positive and less stressful toileting experience.

3. Breathing Techniques: Teach the child simple breathing exercises to promote relaxation. Slow and deep breathing can help alleviate anxiety and sensory discomfort during toileting. Practicing these techniques regularly can contribute to an overall sense of calm. Sensory-Friendly Toileting Environment: Modify the toileting environment to accommodate sensory sensitivities. Consider using soft lighting or using a noise reduction strategy to address anxiety related to the flush. Solutions like white noise machines or flush mufflers can minimize sudden and potentially distressing sounds, providing a more soothing experience.
   

Allow the child to use a lower toilet seat, a potty chair or squatty potty step stool: This adjustment can address both anxiety and rigidity, creating a more secure and comfortable seating arrangement to reduce anxiety.

Visual Schedules: Utilize visual schedules to create predictability and routine surrounding toileting. Clear and visual step-by-step instructions can help the child understand and prepare for the sensory aspects of the toileting process.

Positive Reinforcement: Implement a positive reinforcement system to celebrate successful and anxiety-free toileting experiences. Some children will respond to praise alone but if your child seems to struggle with praise alone you may need to figure out something they are excited about earning for pooping in the potty. It is important to take note though that if this is not successful after a while, you may be inadvertently creating a power struggle with your child, and it may be more effective remain neutral and not stress whether or not the child is having bowel movements in the toilet.

Gradual Exposure: Introduce the child gradually to new or different bathrooms. Starting with short visits allows the child to acclimate at their pace, easing anxiety about unfamiliar surroundings while softly challenging rigid thinking.

Interoceptive Awareness Activities: Incorporate activities that enhance interoceptive awareness. Engage in discussions about how the body feels internally, encourage the child to notice bodily sensations, and gradually introduce the concept of recognizing when it's time to use the toilet.

Navigating sensory challenges requires a combination of patience, creativity, and an understanding of the individual child's sensitivities. By incorporating relaxation strategies, digital distractions, breathing techniques, and sensory-friendly adaptations, parents can help children with autism manage sensory discomfort and build positive associations with toileting. As always, adapting strategies to align with the child's specific needs fosters a supportive and personalized approach to toilet training.

Capitalize on Preference for Routines

Embracing their love for routine can be a game-changer. One practical strategy involves incorporating a set toilet time after each meal. This approach provides a structured opportunity for them to engage in the toileting process. This routine not only aligns with their love for predictability but also establishes a regular interval for toileting, increasing the chances of successful bowel movements in the toilet.

Don't Let Them See You Sweat

Adopting a casual-it's not that important attitude is perhaps the most important aspect of dealing with stool withholding. The last thing you want is to create a power struggle or intensify the struggle that already exists. The emphasis here lies not in the outcome but in the process, and not making a big deal out of whether the child does or does not have a bowel movement in the toilet is pivotal.

Children with autism may be particularly attuned to the emotional atmosphere around them. Overreacting to success or failure can inadvertently create stress and anxiety, hindering the learning process. Instead, maintaining a calm and unassuming demeanor communicates that toilet time is a routine part of daily life, devoid of unnecessary pressure.

To foster this nonchalant approach, consider implementing the following strategies:

1. Casual Conversations: Integrate casual discussions about toileting into daily conversations. Normalize the topic, making it an everyday aspect of life rather than a special event.

2. Neutral Language: Use neutral and matter-of-fact language when discussing toilet activities. Avoid attaching excessive praise or disappointment to outcomes, focusing on the process itself.

3. Consistent Routine: Incorporate toilet time as a consistent part of the daily routine. When it becomes an expected and regular activity, the emphasis shifts from the outcome to the habit itself.

4. Celebrate Effort: Acknowledge and celebrate the child's efforts rather than placing the spotlight on the end result. Positive reinforcement for participating in the process encourages a healthy approach to toilet training.
   

By downplaying the significance of success or failure and maintaining an even-handed approach, you create an environment where the child feels less pressured and more comfortable with the learning process. Remember, the journey of toilet training is as much about establishing positive habits and reducing anxiety as it is about achieving specific outcomes. Embracing nonchalance can transform the toilet training experience into a more relaxed and positive endeavor for both parent and child.

Conclusion: Nurturing Success

Embarking on the journey of bowel training children with autism presents unique challenges, but with patience, understanding, and some tailored strategies, success is within reach. From addressing fears of novel experiences to navigating sensory challenges, anxiety, and constipation, each step requires thoughtful consideration. It's crucial to recognize that every child is an individual with their own set of preferences, sensitivities, and pace of progress. As a parent who has faced these challenges personally, I encourage you to approach toilet training with a blend of compassion and persistence.

Remember, the road to success often involves trial and error, and setbacks are a natural part of the process. Celebrate small victories, remain adaptable, and seek support from healthcare professionals when needed.

Additional resources

Looking for some additional resources on this topic? Check these out.

Free Social Skill Story

Using social skill stories can be so helpful to teach social skills to children with autism. If you are working on teaching turn taking, try this free Taking Turns social skill story today!