Arielle, 3 years
June 11, 2019
Arielle is aged 3. Her parents came to the clinic on June 11th, 2019. She’s still bedwetting but controls her bladder during the day. She does one or two small bowel movements in her underpants.
They occur anywhere and everywhere. This situation has been carrying on for almost a year. During that period, there were two isolated incidents in which she had a bowel movement on the toilet.
She can sit on the toilet but can’t poop there. So far her parents haven’t looked for any professional help. They’ve tried again and again to persuade her, using gifts, explanations, examples, and all sorts of bribes. Occasionally, she gets tremendously angry. Her kindergarten teacher and grandparents are involved in the matter and try to put pressure on Arielle. In general, she functions well in various life aspects.
I explained to Arielle’s parents that this is a question of a powerful anxiety that has taken control of the child. In fact, there are two anxiety factors at work here. The primary anxiety was having a bowel movement on the toilet bowl. Following reactions from people around her, the lack of understanding that anxiety is the problem here, and the demands placed on her to poop on the toilet, another form of anxiety developed—one about pooping in the toilet bowl. It’s expressed in small, partial bowel movements that reveal she’s withholding and trying to prevent any bowel movements at all.
I outlined to her parents the rules of treating toilet anxiety and they left the clinic with a clear, detailed action plan.
On June 19th (five days after the clinic meeting), I phoned her mother, Hodaya. She related that they’d started applying the approach. Arielle was cooperative about sitting on the toilet bowl after having soiled her underpants. She had started announcing, after dropping poo into the toilet, that she had more poo, and asked to go on sitting, without underpants, on the toilet bowl. Her mother was astounded to see that Arielle was doing it—of her own accord—in the toilet. Arielle was so delighted and asked to phone her father and her kindergarten teacher and tell them the news.
This is the letter I received from her mother after that phone call:
“Our story started ten months ago. We started toilet training Arielle following urinary tract infections caused by diapers. Arielle wasn’t really ready but we had to take that step. In terms of peeing, Arielle started to pee in the toilet but not pooping…She stubbornly refused to poop on the toilet, only in her underpants. We tried everything: encouraging her, promising gifts, we got mad, read stories, absolutely everything, but nothing helped. That’s how we’ve spent the past ten months, and as parents, we experienced immense frustration. As a result, Arielle grew frustrated too and disappointed in herself.
We came to your clinic totally unoptimistic, but you gave us hope—asked questions about Arielle’s problems, and finally, the problem got a name—toilet anxiety. You said we shouldn’t talk to Arielle any more about the bathroom and the toilet bowl, and every time she soils her underpants we should say, “Great—the main thing is that you pooped.” You also said we should change her when she sits on the toilet bowl, pull aside her panties and let the poop fall in; we should laugh at the splash! created by the falling poop, and get rid of her anxiety that way. And you also said that if it happens and she does poop in the toilet, we shouldn’t be too thrilled, just say words of reinforcement and that’s it. I was surprised when you said not to involve the kindergarten staff because I’m a kindergarten teacher, but you said it was so that Arielle will feel comfortable at home and not so much in the kindergarten.
After our meeting, we started implementing the method, and then once there was soiling in her underpants we followed your instructions. Arielle was entertained by the splash when we changed her on the toilet. The second time we changed her she continued pooping in the toilet, and said to us, “I’ve got more”…We were in shock, but only inside, we didn’t reveal how delighted we were. We remembered that you emphasized we should curb our enthusiasm, so all we said was, “Way to go, Arielle!” Later she pooped a little more in her underpants and then went onto the toilet bowl. And today I could have almost screamed with joy…Arielle came to me and said, “Mom I need to poop.” I asked her, “And where do you want to poop?” She said, “In the toilet.” I took her hand and she sat on the toilet bowl and suddenly there it was—poop. At that moment I wanted to burst with happiness but again remembered to be restrained, and said, “Well done, Arielle, you’re a champion!” She looked at me and wanted me to be more overjoyed and then she said, “Mom I’ve pooped in the toilet!” I reacted by just saying, “Yup, you’re a champ.” She said, “I deserve a present, Mom, and I want you to phone Dad and the kindergarten teacher and tell them I pooped on the toilet.” I phoned them, and Arielle shared the news with them. She got encouragement from her teacher, who promised that the next day she’d get a medal from her.
I phoned to ask your advice about what we should do about the gifts she’s expecting and—more than this—how to continue. You recommended telling Arielle that the biggest gift is that she successfully pooped in the toilet, but she’ll get a gift anyway because she asked to poop of her own initiative. And you also said we should still restrain our enthusiasm with her, when she poops again in the toilet, and just give her reinforcements. Even if she does it again in the toilet we should say, “The main thing is that you did a poo,” but not to remind her about the toilet.
From here on we’re continuing the process…and there’s no doubt we’re totally thrilled.
Dr. Kushnir, thank you so much for everything, we’ll let you know what happens ahead.
Goodnight and loads of thanks.
Alon, 2.9 years, began treatment via Skype
June 14, 2019
Alan still wears a diaper at night. During the day he restrains himself for long hours—both peeing and bowel movements. He’s just terrified about having a bowel movement. For the past two days consecutively he hasn’t had a bowel movement. Finally, it escaped and soiled his underwear. Everything began a week ago when his mother removed the diaper of her own initiative. The boy himself showed no sign he was interested in going diaper-free. Immediately, he started releasing urine and feces in his underwear. His reaction was hysterical when he felt he needed a bowel movement, and when he asked for a diaper, his mother refused. The situation is going from bad to worse. He holds it in for entire days, at home and in kindergarten, both bladder and bowels: he’s in tremendous psychological distress and has also resumed using his pacifier. His mother, Sharon, told us that although he’s very aware that she’s a single mother and lives peacefully with this situation, he’s now starting to constantly demand a father (who of course doesn’t exist in his life). In view of his tremendous misery, his mother requested a Skype session with me on a Friday before the weekend, so as not to wait a few more days for a meeting at the clinic. In general, she described him as a well-developed, joyful, and sporty boy, who is active, full of self-confidence, and who functions well in all aspects of his life.
I outlined to her the rules of treating toilet anxiety and she finished the call with a clear, detailed action plan.
Three days later, on Sunday, June 16th, Alan’s mother told me that she’d carried out all the instructions and was hoping to see less mental stress in the boy who had resumed pooping in the diaper.
A few days later, on June 20th, Sharon called again to report that her son was completely free of mental anxiety. He’d been pooping in a diaper without holding it back. He’d asked when he needed to go and had also started peeing freely in the toilet—at home and in kindergarten. We agreed that we’d let the situation stabilize over the next two weeks and then gradually start introducing other activities to eradicate his toilet anxiety.
Aline, 4 years
February 12, 2019
Aline controls her bladder completely, both night and day. She poops in her underpants. She tends to restrain herself for several days then develops serious constipation. She’s incapable of sitting on the toilet bowl. During the day there are several incidents of escaped feces pellets in her underwear. She’s never done a bowel movement on the toilet. She also suffered prolonged bouts of constipation in early infancy and was once diagnosed with a fissure (a fissure is a sort of bleeding from the anus when large and very hard feces passes through—which happens after prolonged withholding). The situation described today has been like this for two years ever since they removed her diaper. To date, the parents haven’t sought professional advice. Both her parents and the kindergarten teacher remind Aline time after time to poop in the toilet, and after she poops in her underpants everyone makes a point of asking her repetitively if she knows where she should poop. Sometimes they have outbursts of anger.
In general, she’s described as a cheerful girl, naughty, sunny-tempered, and intelligent. She’s is very stubborn, opinionated, and sociable.
I outlined to her parents the rules of treating toilet anxiety and they left the clinic with a clear, detailed action plan.
On February 20th in a phone call, Aline’s mother, Victoria, shared that Aline was pooping much more freely now, and had no constipation attacks. She even asked now and then to poop in the toilet, though she didn’t actually do much. There had also been cases of wetting.
On March 6th (three weeks after the clinic meeting), I spoke with Victoria about implementing the principles of the moderate approach. At home, Aline twice took the initiative to poop on the toilet. In kindergarten, they decided to give her a diaper since she soiled several times a day and it attracted insults from the other kids. At home, she wore underpants and did large bowel movements and with a higher frequency than before the moderate treatment began.
Together we decided to continue with the same method.
There were cases of soiling, and ups and downs.
On April 9th (two months after treatment started), Aline’s mom reported that, twice that day, she’d managed to poop in the toilet on her own initiative.
On June 10th (four months after treatment began), her mother again reported that Aline had pooped in the toilet, on her own initiative, twice that day.
In view of this further progress in the matter, on June 20th, we decided in coordination with the kindergarten teacher, that Aline would wear underpants to kindergarten.
Her teacher told Victoria that she’d done three poops in the toilet, all of which she’d initiated.
On the morning of June 23rd, 2019, Victoria emailed me:
“After we’d tried all sorts of methods—prizes, gifts, a potty—nothing worked and we looked for professional advice. Your instructions were to stop all pressure on the kid and give her legitimacy to poop when and where she wants. The main thing is that she poops. I have to admit that it was a very tough task for us, her parents. Because of course changing clothes five or six times a day is really heavy, but slowly we learnt we need to let go, not to put pressure on her. Everything has to come from her own understanding. We tried not to talk about it at home and if sometimes there were small successes, we didn’t hand out prizes or celebrate, just tried to keep a regular routine.
It took quite a long time because the whole question of pooping is very traumatic for us and we knew it’s a process that needs a lot of patience—we didn’t want to use the option of enemas.
After three or four months suddenly she decided that she was going to the toilet and she pooped there even without asking. She just sat down on the toilet and it started—once a week, twice a week—until ultimately—with your instructions—we sent her on a Friday to kindergarten with underpants. In fact, it was the kindergarten teacher who told us she’d pooped three times in the toilet. I have to note that the kindergarten didn’t collaborate with us and pressured Aline to wear diapers because the staff was fed up with changing her. It was only at home that the whole issue was handled.
In the kindergarten, the behavior was very different. And nonetheless, we managed to give her the confidence to poop in the toilet—not in diapers, not in underpants. It’s very clear to us that there may be cases of regression but overall I see that she has the understanding—and that’s what we wanted to achieve.”
Aviv, 3.2 years
September 6, 2018
Aviv’s parents came to the clinic on September 6th, 2018. They told me that Aviv is still sleeping at night with a diaper. During the day he almost completely controls his bladder. They constantly remind him to go and poop in the toilet. He restrains himself and has bouts of constipation lasting three days: then when there’s no choice, he poops in his underpants. In most cases, it’s a full bowel movement. Soiling happens everywhere and generally, he doesn’t bother to announce it and continues walking around with it.
That situation has continued for some four months; since his parents took him out of diapers. The kindergarten teacher and his grandparents are also involved in the problem and constantly try to persuade him to sit on the toilet. His father thinks they should resume full use of diapers, and postpone the whole issue of training. The mother thinks otherwise. She’s the one who changes his clothes generally and she sometimes has angry outbursts. So far, they haven’t contacted professional people. He is described as a very smart child, with rich language, who adores music. He’s a little clumsy in motor terms. He has been diagnosed with extreme sensory sensitivity.
I outlined to his parents the rules of treating toilet anxiety and they left the clinic with a clear, detailed action plan.
On September 30th, 2018 (three weeks after the clinic meeting), Aviv’s mother reported a major improvement in his bowel movements, which had become more frequent, with less constipation and less stress. He’d collaborated cheerfully with dropping the poop into the toilet.
On November 1st, 2011 (two months after the first meeting at the clinic), his mother reported another big improvement and this is what she wrote:
“Since our meeting at the clinic two months ago there has been a super significant change for the better! Unbelievable! We thank you so much! From a child who would soil his pants often two or three times a day, with constipation of two to three days consecutively, he’s now sitting on the toilet every day. And it’s all his initiative and under his control, today (and in the past month) he soils himself maybe once a week only, the cases of constipation are few and far between and it’s all his full initiative. It’s an awesome method that gives parents a well-structured format, totally practical and super professional. Our Alex is 3.3 years old and it’s hard to believe where we were just two months ago. Huge thanks to you, from the bottom of our hearts.”