Families Withholding Toilet anxiety Anxiety is a living body,Poised beside us like a shadow - Amanda Gorman Many people, of all ages, find toilets unpleasant and sometimes worrying. It is particularly common in children and can impact on their bowel and bladder control and function. It is important to recognise toilet anxiety in children and the effect it can have on them, so that they can be supported to overcome their fear. This can avoid further problems developing and focuses on the underlying cause. What is anxiety? Anxiety is the emotional response to an unfamiliar or alarming situation, and is linked with physical changes in the body. It is a normal response which can help us learn and adapt – you may have heard it described as ‘flight or fight’. It can sometimes be fun and exciting, such as in stories like ‘Going on a Bear Hunt’ or whilst watching films, like Star Wars. New situations can often make children anxious, but this feeling usually reduces quickly and they start to feel better. Why toilet anxiety? Toilet anxiety may be triggered by an unpleasant experience, such as a noisy or smelly toilet. Children might remember this each time they go - leading to an association of anxiety with going to the toilet. They may also start to hold in wee or poo to avoid using the toilet. This can lead to constipation as the poo is not let go and this can result in a large uncomfortable poo, causing even more increased anxiety. Memories of an unpleasant or painful poo, following constipation can last for a long time, even if the poo has returned to normal so the anxiety may continue. Anxiety following an unpleasant experience can be hard to forget and overcome. It can also continue to affect children’s confidence and behaviour. Fear is often about the unknown, and may be linked to imagined monsters and scary things, snakes in the toilet, and dangerous germs (Toilet cleaners ‘kill all known germs’ after all!). Physical effects of anxiety These may include: Nausea and stomach ache Rapid shallow pulse Rapid shallow breathing (even triggering an asthma attack if children have this). Headaches Wee and poo accidents Faints Emotional effects of anxiety These might include: Panic attacks Tantrums and meltdowns Withdrawal Freezing Sleep problems and nightmares Irritability Clinging Distress and exhaustion Denial and resistance to engage with the problem Possible causes of toilet anxiety: New, unfamiliar toilets Constipation and/or a painful poo Soreness and skin inflammation round the anus or round the urine outlet Different clothes e.g. pants which may be different and feel strange The sensation of wee and poo coming out and losing part of yourself Splash back from the toilet Will it stop? Feeling they could fall down the loo Background factors: Individual personality Family changes and stress e.g. new baby, moving house Potty training (this is the first time a child needs to actually engage with their wee or poo) Starting school and/or nursery Being denied access to the toilet at school Being called names or bullied Inability to cope with new situations Trauma Health issues Developmental conditions e.g. autism (ASD) Children with concentration difficulties (ADHD,ADD) Sensory factors: Many children may be upset by too much sensory stimulation including Visual - bright lights, reflections, glare Hearing - echoes, sounds of toilet filling and/or flushing, hand driers Touch – the feeling of the toilet seat, toilet paper, clothes being down round the legs Smell - highly perfumed bathroom products and cleaners, the smell of poo Balance - feeling of unsteadiness especially on a strange or different toilet Proprioception - understanding where your body is in space and in relation to the toilet Interoception - understanding and feeling the sensations from inside the body, including sensations from bowel and bladder activity Responding to sensory factors: Analyse toilet environment Reduce the amount and impact of unpleasant sensations Make the bathroom familiar and friendly, with games music and pictures Provide distractions and more stimulation for those who need it Our sensory factsheet has lot more information on supporting children with sensory needs. How to help toilet anxiety: Here are some ways to help and support your child: Accept and recognise the child’s anxiety and analyse the factors contributing to this Check bowel and bladder function. Many children are constipated too and that will need treatment before progress can be made. See our advice for children with constipation for more information. Build confidence with other activities and skills e.g. washing hands, putting on socks, being helpful Break up the task into small, easy steps that can be gradually built on Use predictable routines Distraction Try to make toileting fun Talk to the child about anxiety Some things to try: Eric’s wee and poo toys Music and songs Videos which explain how toilets work Tactile activities e.g. fiddle toys, putty, play dough Joke book - laughter is a great way to relax children Visuals e.g. kaleidoscopes, spinning danglers Gentle massage, tummy, feet or hands Sounds e.g. waves, music, bird song Slow, deep breathing Thinking about a favourite place or activity Using rewards Things to try: Reward effort as much as success Keep rewards small and fun A lucky dip box Activities and targets for older children Peace and quiet may be preferred by some children. Things to avoid: Giving unreal targets Asking too many questions- use “I wonder what…”? Getting cross - but you can be cross with the wee and poo coming out in the wrong place! Talk about how annoying it is that the wee/poo is misbehaving again, and how you and the child will have to teach it how to behave. Think about the following: It’s always important to consider and assess anxiety Try to see the situation from the child’s perspective Toilet anxiety may be linked only to toileting activities Anxiety improves with experience and familiarity Parents and carers need support too, it is stressful dealing with an upset child Consider and discuss school toilets Make sure children get used to other toilets (these can be scored out of 10). Remember: Anxiety usually improves with experience, support and growing up.