By Heather L. E. McKay
This is probably one of everyone’s worst fears – to walk into a room to find the walls, floor, objects, fittings and fixtures and even the ceiling smeared with faecal matter. The description brings to mind the movie with Eddie Murphy “Daddy Day Care”, when the child states “I missed”, and Eddie precariously checks the bathroom to find out what “I missed” meant. Only to be horrified in every direction he looks.
What’s your first instinct in this scenario? Is it to run away, to scream, to cry, to gag? These are all valid responses to something you never thought would ever happen, especially not in your own home. But how you react and how you move forward will affect the whole family in some way. Your mental health will most likely suffer, and if it occurs more than once, you may need to seek external mental health supports.
After the mess is cleared – either from getting down and scrubbing it all away, or from ritualistic bon fire (which BTW would make the smell worse)– you will most likely have a desperate need from preventing it from ever occurring again. But what do you do? How do you stop it? Why did this occur in the first place? What possessed your child to do such a horrific and unsanitary thing?
Please try (I know it’s not your first instinct, as it’s not mine either) not to yell, scream, berate etc. Yelling at a disabled child never helps the situation. You will, most likely, feel the need to yell, scream and berate – but try to do it elsewhere where it won’t scar or scare the child. A scared child will go into fight/ freeze/ flop/ fawn/ flight/ flex response to trauma – just as you did when you first saw the mess (please see my book 4 for more information about the “Flex” response to trauma). Two people within the thrall of a trauma response will get nowhere. There will not be rational thoughts or solutions during this period. Wait until the situation has calmed and everyone can think rationally and calmly again.
But what is the first step? Well the answer will rely heavily on your family and how you usually handle situations, but it’ll also depend on the child and the issue.
Some families first step is to make demands – to tell the child that it’s never to occur again – and expect immediate and complete compliance. But for a disabled child that may not understand the situation, or who is in a state of ‘can’t’ – this will be close to impossible to achieve.
Other families first step might be clean it up and try to forget it ever happened – hoping that it will never occur again. They “sweep it all under the rug” so to speak. They “plan ignore” it, in the hopes that ignoring it will make it go away. They believe that it is ‘attention seeking’ behaviour, that if ignored – will magically stop. Please remember that children connection/affection seek -not attention seek. And that all behaviour is communication – they are communicating with you. You may not like the way that they communicate, but ignoring it just invalidates that child and their unmet need. It’s neglectful to ‘plan ignore’ a child who is trying to communicate, and it helps no one – but it does cause trauma to the child.
Other families may find other ways towards their first step – but which is best? which suits your family? and more importantly – what suits the child? Only you and your family will know the right direction to take that suits you all. This blog about poop smearing is only here to give you ideas and to help you to find some different approaches and directions to take – depending on the child and the need. It’s up to you to figure out what is going on, and how to ‘fix’ it… not the child – just the poop smearing behaviour.
Head over to my ARFID blog on the website: mckayandmckay.com to read about behaviouralism in the blog “Treatments for ARFID in autistic and ADHD people. The good the bad and the ugly”. It’ll give you some information about not changing the child – and why it’s dangerous to do so – that applies to poop smearing and incontinence just as much as it does to ARFID and other eating disorders. Remember that ED’s are often very tightly linked to incontinence and to gut/ bowel/ and bladder health. If you are going to treat/ support incontinence, it might be very important to simultaneously support healthy eating and drinking.
What would my first step be in the above scenario? As always, it would be to investigate the why. I’d want to know why. But a non-speaking child, or one who doesn’t understand their sensory needs or their interoception may be unable to tell you the why. So, I’d need to work backwards. Making sure they have robust communication methods (AAC’s) to support whole language and complete communication needs to come first; as one of the reasons for poop smearing can be frustration in being unable to communicate. If you eliminate this first (possible) reason – because your child has access to robust AAC, and they feel safe and secure in being able to communicate – you can move onto investigating further. Eliminating reasons and causes along the way is the best way to find an eventual solution.
Just because you think your child ‘can’ communicate their needs, doesn’t mean they are actually always ‘able’ to. Disabled children can often have processing issues, emotional regulation issues, they can become situationally non-speaking, or things like dyspraxia, motor disinhibition and other diagnoses or problems like executive dysfunctioning can affect the ability to communicate consistently or effectively when they need to. This is why yelling or blaming can actually set a child back. Because they may have been unable in the moment the smearing occurred, and then equally unable to explain afterwards.
Feeling safe and secure often frees up our neuropathways and messaging systems – so that speech or communication (by any means possible) suddenly becomes available again. When we receive too many messages simultaneously, it causes a traffic jam, which can sometimes lead to being unable to communicate, but it can also sometimes lead to things like poop smearing, where the brain/body makes mistakes or can’t control our actions (motor disinhibition). If this is the issue – dropping demands and creating safety is paramount to return the nervous system to a reset/ calm state.
Being calm and safe should always be the first step, in my opinion- but in times of stress we often skip this step, or we don’t stress the importance of it enough, and don’t truly reach the mind/body state of ‘safe’.
There can be many reasons why children poop smear. If you check out my book 2 (Co-occurring Disabilities) you will find a lot of great information about this under the heading ‘incontinence’ and ‘poop smearing’. There’s not a lot of support out there for parents who experience this – and that’s why I wrote my own book on the topic, and why I’m here trying to add more and more useful information weekly. Below is a short list of reasons why children might poop smear, and the corresponding solutions:
- SPD: they feel a need to touch, smell, look at truly feel what their body produces – sometimes in order to understand what it is, what’s its purpose and how it works etc, or they just feel a need to experience something of similar texture – smell or consistency etc.
- To solve this problem, you will need to identify which it is. If they are curious – it’s best to do a deep dive into it – not the poo necessarily; but the information about their bodies, about poop and wee and all things gross and disgusting, and fascinating and truly amazing about the human body. Getting a doll that shows the different organs and how they work can help. Using tubes and things to show how food is eaten, digested and expelled is great for understanding science and biology too.
Using petri dishes and things to analyze and look at poop and similar poop/texture things can help them to truly understand what poop is and it’s purpose. Autistic people usually have very strong needs to investigate things fully and to understand things in great detail – it’s why we make great scientists and researchers- because we will keep investigating when our NT counterparts have had enough.
- If it’s a sensory need: find things with the same/ similar texture to play with. Eg: food is often the best bet – because they can also eat it if they want to fully immerse themselves in all of their senses (including interoception, vestibular input and proprioception). I’d also recommend doing it in an area where they can sit on it, roll in it and rub it all over them.
Things like: Peanut butter, jam or sticky sauces and marinades, or a mixture of all of them – this helps to create different smells and experiences. (If it’s the smell they are interested in, maybe try adding something like a stink bomb – if you can cope and do it outdoors). Some people have reported using mud, different types of dirt and rocks, playdough and pizza dough, fidget toys shaped like poop, getting a bucket of water and showing them how to drop it into the bucket to make that ‘splash’ noise you’d get in a toilet. Getting poop toys- there’s so many on the market it’s kind of ridiculous – your child isn’t the only person in the world fascinated with poop – there’s a whole adult industry for it; costumes, toys, fishing for poop, poop basketball – etc etc etc.
- Constipation: this one is a little more difficult to overcome and to deal with, especially if they withhold their poop, refuse to take laxatives or softeners, or they become impacted. It is a huge concern, but it is treatable.
The main reason for poop smearing when constipated is that the poop becomes trapped or stuck in the lower colon (exit sphincter point of the rectum). They may feel the poop sitting in the rectum, but not be able to push it out. This is a truly hideous feeling for someone with SPD or constipation issues – they sometimes become desperate to get it out; and put their finger into the rectum to pull out the poop manually – to relieve the pressure/ pain or sensation of having it stuck.
They then don’t know how to get rid of the residue on their hand. They sometimes will react in a way that later they themselves do not even understand. If they are a germaphobe, or person with poor motor skills, or someone who has motor disinhibition, they may react in horror or disgust or react without knowing what they are doing – and will wipe it off on the nearest surface – to rid themselves of the new hideous sensation that is attached to their hand. Or sometimes they know exactly what they are doing but can’t think rationally of how to get rid of it, or they honestly don’t know how to get rid of it.
- You may need to solve this in multiple ways and steps. First you need to address the constipation – either through medication, and/ or diet and exercise. Not becoming constipated will be your first go to. A laxative that pushes the poop through (so it is less likely to get stuck in the rectum) is a great idea. Most families recommend Dulcolax Drops (no matter what country you reside in), because it’s available everywhere, it’s colourless and flavourless and is great for people with eating disorders. Follow the directions on the box, and always seek professional medical advice before using any sort of medication.
- An OT will hopefully be neuroaffirming and able to help you teach your child some fine and gross motor skills to be able to clean their bums and their hands/fingers properly in these situations instead of using the wall/ floor etc.
They can also help find suitable toilet steps that can elevate the legs to get the optimum seating position for full evacuation. They may also be able to recommend some tools that may assist in wiping bums. Eg: there’s a bariatric bum wiper that looks similar to a shoehorn – you place the toilet paper in the hole in the horn and then use the wiper to wipe your bottom instead of your hand – then dump the paper as usual. But the child would also need to be taught properly how to use something like this.
OT’s can come up with plans and strategies to assist with mobility and toileting – but please make sure they are neuroaffirming. I’ve had some very bad experiences with some OT’s that want to use behaviouralism – and it’s backfired every single time – do not use behaviouralism in potty training – it leads to all sorts of trauma and things like stool withholding.
- A pelvic floor physical therapist can help to teach/train your child to better use the muscles in their bottom to assist with full evacuations without pain or mess.
- A paediatrician or dietitian may be able to help find medications or a diet that will help with fiber and nutrition that can assist with proper digestion and bowel movements.
- I’ve had some parents that have actually found chiropractic care has helped their child to sit straight and have the right posture for elimination. Thinking outside the box often finds solutions in odd places. – whatever works, go with it.
- Interoception issues: Some children won’t know they’ve pooped. They may have little to no feeling in the rectum, and the poop slides out (into their pants) without them knowing. This is usually caused by a stretched colon from too much or consistent episodes of constipation. But a child can be born with colon or internal issues, or with SPD issues that can also cause these types of problems.
The child may then feel a strange sensation on their bottom, or perhaps smell something. The first instinct of the child will be to use their hand to feel the area and find out what is causing the strange sensation. When they pull their hand away from their bottom and see what is on it – yet again they have an instinctive reaction. Their reaction is usually to ‘wipe’ it off – and usually kids will look for the nearest surface to achieve this goal. Teaching them what to do (not -what not to do) in these situations is paramount.
- Easy and quick access to wipes, sinks or their parents/ closest adult (who can help them to a sink immediately) will be of highest importance.
- Teaching them how to identify that they’ve pooped without having to touch it, is going to need the same process as in the previous dot point (eg: an OT, a PT, a paediatrician and possibly medication to shrink the colon back down again – so they regain control of the elimination).
- Finding an OT that is experienced and neuroaffirming in interoception training may be difficult… check out Kelly Mahler (an OT) on her Facebook group “Interoception the eight sense” for information and perhaps recommendations for OT’s or training near you.
Don’t forget to investigate and eliminate any co-occurring disabilities or issues that may be affecting the bowel, bladder, stomach or digestion. If you miss a medical diagnosis like coeliac, diabetes, IBS, twisted colon, prolapse or anything else – it could be dire, but also, it will be nigh on impossible for the child to heal and recover. If you believe there’s something more going on than what I’ve listed above – and your doctor isn’t listening to you – try and get a second opinion. I know that’s sometimes a privilege – but if these types of issues go untreated and undiagnosed, some of them can become life threatening. The Triple Empathy Problem can prevent secondary diagnoses being discovered or treated in Autistic or ADHD people – but the likelihood of us having a secondary or third or even tenth additional issue is very high indeed. Doctors need to start listening to us, but more importantly – believing us.
Get an advocate or someone involved if you can, and/ or if you don’t feel you have the spoons or ability to fight. A good advocate, friend or supportive family member can be the difference between life and death or good /poor mental or physical health.
Poop smearing can also be a sign of something else entirely. I do know of an adult that was discovered and diagnosed with Bipolar after an episode of poop smearing. Getting the right diagnoses first and discovering the root cause is the most important thing you can do when trying to ascertain how to treat it. The wrong assumption about the root cause can cause poop smearing to continue indefinitely. And putting the patient in a onesie or restrictive clothing to stop the issue is not ideal either. Yes, it may help to be able to access the community without massive accidents, but it is not a long-term solution and can actually do more harm than good. Finding the cause and helping /supporting or treating the cause is preferable.
Using Restrictive clothing is a behavioural technique that is usually enlisted to hide or to stop the behaviour – but it isn’t respectful of the patient or their unmet need. The autistic community is usually against restrictive practices unless it is to save the person’s life. Eg: using a safety harness for a child that hasn’t yet learnt road safety, or who elopes and becomes lost – this is a safety concern and is necessary to save the child’s life until the child can learn these vital skills.
Restrictive clothing has been known to save the lives of patients that tear off all their clothes in public – because that clothing has stopped them from undressing, and remaining clothed has prevented them from being a arrested, accosted or molested. But a far better solution is to find out why they are tearing their clothes off – are they hot, itchy, uncomfortable, sweaty, something in the clothes like a tag, or is the material itself causing pain, are they dysregulated or in meltdown? Investigate the cause of the behaviour and prevent/ support or remove the thing that is causing the pain – don’t stop the behaviour by restricting them…. That’s a behaviouralist method, and it can be highly abusive to the disabled person and their needs. Remember that behaviour is communication – and if you prevent the behaviour (instead of understand the behaviour) – you are in effect stopping them from communicating – which is a human right.
I hope this blog about poop smearing has uncovered some useful information for you and your family, and that you can identify the need and what they are communicating. For cleaning tips and tricks about getting poop stains or the smell out of furniture or carpeting, please look out for future blogs, or ask other members in the “Neurodivergence and Incontinence Support” group for some assistance. And don’t forget to take care of your own mental and physical health when you are supporting or caring for a disabled person – you cannot help others if you don’t first support yourself.