When Gracelynn was 3, she was fully potty trained and could poop properly like any other kid. But one or two accidents at preschool suddenly sent her confidence plummeting. When teachers finally asked her mom, Justine, to pick her up in front of the entire class, saying Gracelynn could not return until she had her bowels under control, the young girl was mortified.
Soon enough, even at her new school, Gracelynn became anxious and caught in a messy cycle: withholding going to the toilet for as long as she could, only to then poop herself four or five times a week.
“It was really weird. It’s like she just didn’t care if she went to the bathroom. She didn’t care if she went in her pants,” said Justine, who spoke with BuzzFeed News and requested her family’s last name be withheld in order to protect their privacy. “She seemed to completely lose interest in doing what was right when it came to going potty.”
For Justine, it felt like Gracelynn, now 5, had forgotten everything she’d learned about a practice that comes — and stays — naturally for most people. Suddenly, she couldn’t even poop properly at home. Worse still, she didn’t feel comfortable talking about her problems. Gracelynn felt ashamed, while Justine felt like a failure as a parent.
“It was really upsetting that my daughter was going through that,” Justine said. “I know deep down that she wanted to do the right thing, but I don’t feel like she knew how.”
Luckily for Gracelynn, there was a solution: poop school.
Since 2015, the Cleveland Clinic in Ohio has been offering group classes for kids aged 3 to 7 to teach them how to poop. Formally known as functional constipation-shared medical appointments — families and staff call it “poop school” — the four-week classes teach kids the basics of digestion, toilet habits, and best pooping practices.
“A lot of these kids, I think, don’t realize that everybody poops — that this is something that all humans do,” clinical counselor Lianne Piorkowski told BuzzFeed News. “So we just also normalize it and talk about how our body turns food into poop.”
Such group classes are rare in the US but not unheard of; since at least 2008, Boston Children’s Hospital has offered a six-week “toilet school” for groups of young children in a program developed by the late nurse practitioner Ann Stadtler, who wrote a 2017 book on the problem. One 2016 comparative study found big benefits for this group approach for kids as opposed to individual treatment.
Experts estimate that 3% of children will suffer from functional constipation, resulting in 3-5% of all visits to pediatricians and up to 25% of all visits to pediatric gastroenterologists. If the condition is left untreated, children can develop encopresis, a condition where children who have already been toilet trained withhold bowel movements, inadvertently or not, and leak liquid stool around the harder stool, thus soiling their clothes.
“Encopresis is such a major source of stress on kids and their families,” poop school program director Katherine Corvi said. “It affects their psychological health and well-being, and it significantly reduces quality of life.”
It’s not just kids who need help from pooping professionals. While the Cleveland Clinic tailors its group classes for children, many adults also suffer from long-term constipation and may require one-on-one help and even retraining on how best to begin pooping naturally again.
Americans make roughly 2.5 million visits each year to physicians for constipation, with about 100,000 of them referred onwards to gastroenterologists. Roughly 1 in 7 people, or 35 million Americans, will experience chronic idiopathic constipation, when they have difficulty passing stools or poop infrequently without any known cause. It’s been estimated that US spending on laxatives is more than $800 million, although that’s likely to be an underestimate that doesn’t take into account over-the-counter medicines.
Treatment of constipation can be made more difficult by our social tendency to avoid discussing such matters, according to Brijen Shah, a gastroenterologist at New York’s Mount Sinai hospital and a fellow with the American Gastroenterological Association. As a result, many patients suffer in silence.
“A lot of people don’t wind up talking about it. They’re kind of embarrassed — they feel like they’ve been dealing with it alone until they wind up talking to a healthcare provider about it,” Shah said. “Some people will tell you that they just think they’ve come to believe that this was normal.”
There are two parts to defecating, each of which can cause problems, Shah explained. First, the body needs to move digested material, aka fecal matter, from the colon to the rectum. Second, we need to coordinate and relax our pelvic floor muscles, which are normally contracted, in order to allow the stool to leave the body.
It’s possible that medication, diet, or a lack of fiber might explain why someone might have difficulty with the first part, but the pelvic floor can also be a problem zone that requires special investigation. According to Shah, about a third of adult patients with constipation are having problems with their pelvic floor. Patients who’ve endured childbirth, radiation treatment for rectal or ovarian cancers, or spinal cord injuries may have suffered damage to the muscles and nerves in the pelvic floor.
For others, though, there may be more complicated psychological factors at play, including stress and anxiety. Children, in particular, tend to fall into two categories, said Piorkowski: younger kids who are too distracted to listen to their bodies and older ones who have pooping anxiety.
“Anxious kids are more prone to withholding,” Piorkowski said. “So if they had a large stool burden or were constipated at one point in their life, they kind of realized, Oh, I can hold it in and I can prevent myself from feeling that again. And then it creates this medical concern because whatever we eat has to come out. It’s this cycle of withholding and unfortunate pain when they go.”
The more that stool builds up, the harder it becomes to pass. Eventually it builds up in the rectum, expanding it like a balloon and damaging its elasticity.
Shah, the gastroenterologist, said he’s encountered backed-up patients who have come up with workaround methods to assist them with pooping. Some have weekly colonic irrigation or massage appointments, while others have turned to herbal remedies. Others try to rely on laxatives or enemas, but Shah has even had patients tell him they will insert their fingers into their rectums or vaginas to try to stimulate a response. Over time, though, these workarounds prove counterproductive to normal pooping habits.
“For some of my older patients, it’s been decades, but they’re just sort of doing what they’re doing,” Shah said. “It’s not until somebody says, ‘You know, it’s not totally normal that you go every five days,’ or ‘We did this CAT scan for a whole other reason and you had a ton of stool throughout your entire colon. We could probably do something about that to help you.’”
In order to retrain or assist these patients, a gastroenterologist might simulate defecation by inserting a catheter with electrodes into the rectum, sending signals to the brain and evaluating what level of stimulation finally prompts a bowel movement in a simulated defecation. Alternatively, they can expand balloons inside the rectum to see at what volume a patient’s brain is triggered to poop. These tests are designed to examine whether the rectum is sending the right signals to the brain or if it’s been overstretched.
If a gastroenterologist suspects a patient has pelvic floor problems, they will likely send them to a physical therapist like Katie Thomas, who works with patients at her clinic in East Grand Rapids, Michigan. As a pelvic floor physical therapist, she’ll work with a typical patient for six to eight visits, leading them in strength and breathing exercises to help them overcome dysfunction that might include constipation or diarrhea, urinary leaking, or pain in sexual activity.
“Just like we hold stress and tension in our neck and shoulders, we can be clenching our pelvic floor throughout the day,” Thomas explained. “So a lot of individuals that are under a lot of stress will start clenching, or [some might] have a habit of holding their urine or stool in for long periods of time, like healthcare workers or teachers.”
Among the most effective techniques for loosening the pelvic floor are deep belly breathing exercises and stretches like the happy baby pose.
Thomas said she finds it incredibly rewarding to work with patients who enter her practice embarrassed, but eventually leave happy poopers who have overcome habits they may have picked up early in life.
“We’re told all the time when we’re children, ‘Oh, go to the bathroom, just in case.’ And then we’re not really setting ourselves up for good bowel habits,” Thomas said. “No one teaches children how to properly poop on the toilet.”
While pooping comes naturally to most people, how to do it properly doesn’t instinctively occur to some. That’s where Cleveland Clinic’s poop school comes in. Before the coronavirus pandemic, six to eight children would meet in person for weekly classes over a month, but lessons shifted online in recent years, enabling others to join from around the country (in-person classes are set to resume in February).
Pooping Best Practices
In the sessions, both kids and parents are taught the biological basics of how and why food is digested — Taro Gomi’s illustrated book Everyone Poops is a core text — as well as proper bathroom practices. Instead of focusing on the occasional accidents, children receive praise when they’re able to independently recognize an urge to poop and are then able to complete the task on the toilet.
“The kids learn in the group about how to have calm, relaxed, comfortable bodies while sitting on the toilet,” explained Corvi, the program director. “And then they have their accidental success, where they have a poop in the toilet [at home], and then they learn, I can do this and it’s not so scary.”
Breathing exercises show the children how to use their belly muscles to effectively move waste material out instead of straining with their butt muscles. This might involve so-called rainbow breathing, where kids move their arms in a large semicircle as they exhale using their belly muscles, explained Cleveland Clinic child life specialist Haley Luedeke. “We’ll also use pinwheels or bubbles, or will tell [the child] to tell jokes and laugh because those belly muscles are kind of what engages it,” Luedeke explained.
Thomas, the physical therapist, advises people to place their feet flat, preferably on a stepstool device like a Squatty Potty that will elevate the legs slightly to mimic a squatting position, which prevents kinks forming in the colon. Many people hold their breath and strain during a tough movement, but she said they should instead lean forward slightly and imagine blowing up a balloon.
Shah also advised people not to push and strain when pooping. “Go, give it a minute or two to see if there’s anything else, and then after that, get cleaned up and move on. Don’t try to push excessively. Don’t sit there forever and ever,” he said. “It sounds kind of crazy, but you don’t want to begin to associate the bathroom as a place of frustration and anxiety.”
For Gracelynn, the little girl who struggled with toileting anxiety and encopresis, the poop school classes she attended this past November soon proved life-changing, according to her mother. While Gracelynn had been nervous during her first class, she soon began eagerly looking forward to each lesson.
“I saw a turnaround within the weeks we were in the class. She didn’t have an accident one time,” Justine said. “And that was the first time in over a year that she hasn’t had an accident in that long a period.”
What proved particularly illuminating for Justine was shifting her focus to Gracelynn’s toileting successes, rather than her accidents. With stickers and positive reinforcement as rewards, Gracelynn was suddenly motivated to poop properly.
Her behavior also changed, Justine said, with Gracelynn reverting back to the sweet and carefree girl she’d been before her pooping problems.
When poop school is over, staff hold a graduation ceremony where the students receive certificates proclaiming them “Super Poopers.” Gracelynn was beaming when it was her turn to be congratulated.
“I’m so proud. I almost started crying,” said Justine, who is 21 weeks pregnant with her second child. “I’m happy that I don’t have to be wiping two butts here soon — I’ll just have to worry about one.” ●
