So many parents misinterpret withholding behavior in children. Many indicate that their child is trying to go but cannot and others indicate that their child does not feel an urge to defecate. Now more insight into this common issue has emerged (JPGN 2013; 56: 19-22).
The authors reviewed their experience with colonic manometry (n=410). 150 patients were identifed as having functional constipation. Among this group, 56 patients volunteered that they had no urge to defecate.
Yet, during colonic manometry, when the first high-amplitude propagating colonic contraction (HAPC) occurred, this was associated with retentive posturing, grimacing or denial of sensation. When the HAPC occurred, the examiner would explain that it was causing pain that would improve if the child defecated. Ultimately, “every patient acknowledged an urge to defecate and successfully defecated.”
One other interesting part of this publication is the discussion of psychological aspects. Do you remember Erikson’s stages (Erik Erikson – Wikipedia, the free encyclopedia)? The authors note, “if toilet training is not achieved or the process involves negative experiences including being shamed into the process, shame and doubt will persist. Shame, according to Erikson, is an infantile emotion and leads to secretive behavior. Therefore, children who failed toilet learning may deny sensations of the urge to defecate…all the while having shame and embarrassment.”
These psychological issues are important in the propagation of constipation. The authors note that, even in children with rectal distention due to chronic constipation which could result in decreased sensation, studies have shown rectal compliance was not associated with treatment failure. Therefore, constipation and soiling are not simply due to a mechanical issue of not knowing when to go.