Constipated Kids Achieve Toileting Success in “Poop School”

Group sessions combine behavioral and GI treatments


It was 1990 the last time new data was published about group treatment for children with retentive encopresis. First-line treatment was still an enema.


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Since then, a pediatric psychologist and pediatric gastroenterologist at Cleveland Clinic have put a new spin on the concept. Begun in late 2015, Toileting Clinic Shared Medical Appointments at Cleveland Clinic have restarted the conversation and renewed hope for families who thought their kids were the only ones struggling with constipation or leaky stool.

“People never talk about it, because it’s poop and it’s private,” says Katherine Lamparyk, PsyD, of Cleveland Clinic’s Center for Pediatric Behavioral Health. “Parents feel shame when they aren’t successful with toilet training. Kids feel shame, too.”

While many families suffer in silence, the condition is widespread. Researchers estimate that, in the U.S., functional constipation accounts for 3 percent of all pediatrician visits and up to 25 percent of all pediatric GI visits.

But merely telling parents and kids that they can get better and aren’t alone only goes so far, says Dr. Lamparyk. Bringing multiple families together is much more effective, she says. Plus, it improves access for those waiting weeks for individual appointments.

GI and behavioral health, intertwined

The Toileting Clinic is a joint initiative of Cleveland Clinic’s pediatric behavioral health and pediatric gastroenterology.

“Toileting problems are not strictly behavioral nor physiological. The aspects are intertwined,” says Dr. Lamparyk. “Effective treatment addresses both. My job is helping kids learn that pooping doesn’t have to be painful and unpleasant, but I can’t do that if they’re backed up.”

Each child in the Toileting Clinic is evaluated by pediatric gastroenterologist Lisa Feinberg, MD. Dr. Feinberg collects details about medications, comorbidities, family history, bladder problems and more. She conducts a physical exam to assess sphincter tone, muscle strength and reflexes. Based on a patient’s history and physical, she may order more testing, including labs, imaging and anorectal manometry.


While all patients already have seen their pediatrician or gastroenterologist about toileting troubles, most are still constipated when they come to the Toileting Clinic.

“The stool consistency we are aiming for is looser than most parents expect,” says Dr. Feinberg. “Many patients need higher doses of softener while we are addressing their anxiety about stooling.”

Four group sessions for kids and parents

At the Toileting Clinic, four to five families gather for four weekly 1.5-hour sessions. Children are ages 3 to 8 and must be suitable for group appointments. (Those with significant developmental delays or behavioral issues should be seen individually.)

Kids and parents split into separate groups. In the parent group, Dr. Lamparyk and Dr. Feinberg lead discussions on the:

  • Causes of functional constipation. Parents learn that constipation is not entirely behavioral nor entirely physiological.
  • Steps of toilet training. Kids can’t be toilet trained while they’re constipated. Bowel clean-outs often are the first step. Next, parents must motivate (not pressure) their children to want to use the toilet.
  • Physiology of stooling. Parents learn which muscles need to relax and which need to push. They discuss dietary factors that soften stool and how various medications can help.
  • Ways to prevent relapse. Doctors explain what could hinder progress and why parents shouldn’t stop treatment too soon.

During each session, children gather in a nearby room with a child life specialist and psychology assistant. Through games and activities, they learn topics similar to the parent group.

After completing the group series, families continue to meet for group follow-ups as often as needed (every two weeks to every two months) until the child is toilet trained.

Enthusiastic patients, better outcomes

“By the second or third group session, kids become so at ease and so excited about what they’ve learned, that they can’t wait to share it with their parents,” says Dr. Lamparyk. “They run out of the room, yelling, ‘Hey, Mom! Did you know poop should be soft?!’ The kids have started calling our clinic ‘Poop School,’ and the name has stuck.”


Patient engagement and satisfaction have led to 100 percent attendance at all four group appointments by the nearly 30 families that have come to the Toileting Clinic since 2015. More than 80 percent have returned for at least one follow-up appointment.

Initial clinical outcomes are encouraging. Within one month, there is a significant improvement in the child’s stool consistency and frequency, and a significant reduction in frequency of accidents. Further, results show improvement in the child’s and family’s quality of life and reduction in parents’ stress.

“The early outcomes are very promising,” says Dr. Lamparyk. “Not only is the Toileting Clinic improving access to care, patients are having much greater success in the group setting. We follow these kids until they’re 100 percent toilet trained.”

Cleveland Clinic’s Toileting Clinic is for children with functional constipation (with or without encopresis) that is not resolved with medication. New groups begin every 6 to 8 weeks. For more information or to refer a patient, contact 216.445.9765.

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