Q. My daughter has two sons, and each has a problem that is affecting their family life considerably.
The elder boy is six and, despite trying hard, he has been unable to stop sucking his thumb, and his teeth are beginning to be affected.
The younger son is three and has started to have problems with his bowel movements — he can’t stop holding on, and despite softening powders and a good diet of fruit and vegetables, nothing is working. He did have a small fissure so obviously connects going to the toilet with discomfort. On day three he is so uncomfortable that he doesn’t want to sit at the table to eat, saying he is tired and wants lie down.
It is awful seeing a generally happy little boy, who has a healthy appetite, crying, screaming and squeezing his bottom. He is potty-trained but has soiled his pants on a few occasions, which he hates. Nursery looms in September, so everyone is worried for him.
Kate
A. Both your grandsons are showing behaviour that can be related to anxiety. You say that their difficulties are affecting family life considerably, which indicates that within their family there is a lot of associated anxiety. This will have an impact on how the boys are supported, and also potentially increase their own anxiety levels as they sense the stress of those closest to them.
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It can be difficult for parents to think in a clear-headed way, and for each of your grandsons to be supported there needs to be a shift in the stress within the family system linked to these behaviours. While this is easier said than done, it is imperative that everyone takes a step back emotionally and thinks calmly about what these two little boys are doing.
Your eldest grandson is a thumb-sucker, which you say is ruining his teeth — it can also lead to problems with speech. This may be an activity that he uses to self-soothe when he is tired or stressed, in which case he needs help to replace it with other self-soothing behaviours. Some children grow out of thumb-sucking, but if it is having an effect on a dental level, a dentist needs to be involved and perhaps a mouth guard used at night to prevent further damage to the teeth.
You can also use a bitter-tasting nail varnish so that when the thumb goes into the mouth during the day the taste causes it to be pulled out. I recommend the excellent book What to Do When Bad Habits Take Hold, by Dawn Huebner. This is designed to talk children and their parents through how habits are formed, why they exist and how they can be broken and replaced with healthy coping mechanisms.
Your younger grandson appears to be faecally withholding, which is terribly distressing and uncomfortable for him and those around him to witness. Parents can feel extremely challenged by this and can often oscillate in their management approach, which is understandable, given that their child is in pain.
You are right to suggest that, after an anal fissure, this little boy associates doing a poo with pain. Obviously the more he withholds, being afraid to pass a stool, the bigger and harder the faecal mass becomes, and so he becomes exhausted and then, when he does pass it, the pain returns.
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You say he is on softening powders but clearly they are not doing the job. He may need a higher or more regular dose to enable very soft stools that he cannot withhold to pass without pain every day, allowing him to get used to the routine. However, some children, despite pooing every few days, may still be impacted and have a build-up of hard and immovable faecal matter in their bowel that blocks daily movement. Your grandson requires assessment by a paediatric gastroenterologist, who can examine him, check for impaction and advise on the dose of the stool softener — the family GP can make this referral.
There is still the psychological issue to deal with. This little boy is now so afraid of pooing that he will need to be systematically desensitised to the anxiety associated with sitting on the toilet. He will need gentle support to learn to sit and relax, which can be achieved by sitting him regularly, making sure he is sitting upright and his feet are on a on a footstool, so his posture enables gravity to help. He could be read to and given bubbles to blow to steady his breathing, so he begins to see sitting on the toilet as fun. Stickers can reward the big boy behaviour.
Some faecally withholding children may poo in a nappy on all fours, others may do it in their underwear. He could sit on the toilet in a nappy if that comforts him, with the nappy loosened over time until it just sits in the pan and eventually is removed from the process. However he does it, there should be no fuss or reprimand, just a business-like clean-up with him helping to flush it away.
The toilet should be decorated with fun posters, with hand towels featuring his favourite storybook characters. He needs an environment that he will be happy to go into and should sit there regularly so he can build up his confidence.
Be aware that behaviour takes time to shift and there will be good days and bad days. If the adults keep calmly focused on supporting the children and following their strategy, these difficult times will eventually be a thing of the past.
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If you have a problem you would like Professor Tanya Byron’s help with, email proftanyabyron@thetimes.co.uk