How to understand our Child’s Constipation?

The diaper weaning process generally becomes the pivotal stone for the consolidation of the personality [1,2]. The child’s resistance to the weaning process reflects his normal emotional development although for the parent it might be a difficult time. The toddler encounters the first time in his life his first major conflict. He wishes to do everything alone and to preserve all his bodily productions against any temptation to take them out from him. On the other side he feels afraid that if he does not obey his parents’ orders of weaning he might lose control over them, he might lose their love for him [2].


Introduction
The diaper weaning process generally becomes the pivotal stone for the consolidation of the personality [1,2]. The child's resistance to the weaning process reflects his normal emotional development although for the parent it might be a difficult time. The toddler encounters the first time in his life his first major conflict. He wishes to do everything alone and to preserve all his bodily productions against any temptation to take them out from him. On the other side he feels afraid that if he does not obey his parents' orders of weaning he might lose control over them, he might lose their love for him [2]. I consider diaper weaning as "a developmental process of the emotional capacity to delay satisfaction, to master retention, to learn from others, release and separation from a toddler's "bodily products". Moreover, resistance enables the infant to assert his individuation and autonomy/separateness [3]. He thus can express his owning of his body [4], of his bodily production and his bodily achievements [5,6]. He asserts that nobody can take out his "productions" without his permission and his willingness to provide them. At the same time the toddler desires to give his "production" in order to preserve his "Jointness" [7] with his parents [2]. These are very important manifestations of the child's autonomy.
In my book The Enigma of Childhood [1] I elaborate in details this first child's conflict; his emotional shift between his need for refueling with love in intimacy [8][9][10][11] and his other need for selfassertion of separateness. As parents we wish our children to be autonomous, to preserve their properties, to be responsible for their belongings and to be creative. We also wish them to be generous and to manage love relationships [12]. These personality's characteristics are mainly molded throughout the diaper weaning [1,2,12].
Let us enlighten the essence of the toddler's resistance to the weaning process: I propose to recognize this resistance as reflecting the innate emotional immune system (Healthy Narcissism) safeguarding all our experiences and especially our childhood experiences, which continue to reverberate along lifespan and provide to the present experiences the senses of familiarity. It means also that we transfer onto our psychotherapists, spouses and even children our childhood pleasures, love relationships as well as our trauma [1,13]. This innate emotional immune system (Healthy Narcissism) is progressed along life and thus, the child, in the anal stage may love his body image and preserve this familiar body image of the Self [1,14]. It represents also an Ego's adaptation functioning [1,2,[15][16][17] to the parental demands of weaning.
I mean that the healthy narcissism is operating to safeguard his Self-familiarity, his body image (like preserving his bodily productions) against invasion of threats to kidnap or give up his bodily productions [18]. Whenever the toddler (like anyone of us) feels that he manages to protect his belongings (his bodily productions as well as his love objects) he experiences feelings of elation, he loves himself (Healthy Narcissism), he is willing to offer gifts to others [1,19] and he may experience a sense of omnipotence [20]. When he fails in preserving his creations, or when the faeces leave the body, the toddler might experience feelings of anxiety of loss, of kidnapping his belongings, of emptiness, of annihilation [21,22] and of losing his love objects. Against such anxieties he (his Ego) can mobilize defense mechanism functioning [1,2,13,16,17] in the form of constipation, or in the form neglecting its belongings, avoiding body care etc., Thus, he imagine (generally unconsciously) that nobody can kidnap his Self-productions.
By describing this emotional dynamic of the toddler, I do not mean that we, his caregivers, have to leave him with his diapers, not at all. I mean to enable us to understand his conflicts and his resistances and respect his needs of owning. Moreover, such normal resistances of the toddler might be repeated and reflect unconscious "conflicts of interests" between spouses. We generally name these "conflicts of interests" phenomena as Ego struggle between people. As parents and any caregiver, we need to find tactics to encourage these emotional immune needs of our toddler and at the same time trigger his willingness to give us his Self-productions and separate from them. Find the way through negotiation, for example, that he would chose to offer his Self-production to the parent in order to receive a reward of his "present" like being big as all of us. That he will push the button of water pule in the toilette or that he will receive a new pants, etc. That might stimulate the toddler's willingness to cooperate with us. It can be by role playing, or games' symbolizations, sublimations [23,24] and especially bargaining of giving and receiving.
So, generally weaning process triggers resistance, often it might activate struggling between parent and toddler other times it might provoke symptoms like constipation and encopresis [25], or enuresis; it might provoke hate [26,27] and destructive impulses. Yet, frequently it might emerge the opposite of constipation like the pleasure of "giving". Constipation is among the frequent somatic symptoms originating in the anal stage (between 1 and five years old). These somatic symptoms are often unconsciously and temporarily produced as passive-aggressive resistance symptoms (defence mechanisms) [1] to parental weaning requests. Yet, these almost-normal anal symptoms may propel the toddler toward persistent pathological symptoms.
Before continuing the elaboration of the sources of constipation, I think it is important to scrutinize the sources of "giving" [19] and differentiate the authentic "giving" emerging out of the true Self in order to share pleasure and love with the object (Ego's adaptation mechanism) [1] from the "giving" emerging out of the false Self [28] in order to please the object and avoid his rejection (Ego's defense mechanism against the abandonment anxiety) [1].
The genuine "giving" may be considered as the parallel of normal constipation while the false "giving" may be the parallel of the pathological constipation. During the anal phase, the toddler is facing controversial pressures: He is facing his parental demand to relinquish his feces and he is facing his own need to master his body including his feces as well as to master his parents' reactions. In these circumstances the toddler might create (Ego adaptation mechanisms) two opposite attitudes, in a parallel process, which will arouse his pleasure: i.
The genuine "giving" arousing his pleasure as, under his control, he gains mastery on his body's relinquishing and his parental approval, recognition and love expression. The toddler experiences his bodily achievements [5] as profoundly satisfying (for his parents and for himself), and feels intense delight [29] in jointness [7] with his parents. ii.
The controlled constipation arousing his pleasure as, under his self-control [30] he gains mastery on his body's holding in (while not exceeding a threshold of pains) while gaining his parental worriedness, love expression or anger (while not exceeding a threshold of worriedness/anger).
Nevertheless, when his parental demand to relinquish his feces is too much stressing, arousing his abandonment anxiety he can't anymore create adaptation mechanism and normal solution and he (throughout his Ego) will activate the defense mechanism in order to protect his Self against being flooded by this anxiety [1]. The toddler might use constipation (pathological) which he can't anymore control and of course will not have any pleasure with it or he might hide behind a false Self, relinquish his feces as a capitulation and pleasing his object without experiencing any pleasure. Whenever the toddler senses repeatedly his parent's respect for his constipation, their genuine pleasure and approval while he providing his feces, he acquires the notion that giving is "good" and he may further develop his pleasure of generosity [19]. The toddler discovers that his giving doesn't deplete himself, quite the contrary, as it remain under his control, it provides him with self-esteem, it strengthens his healthy narcissism [1,14,31,32] and he is rewarded by the object's gratefulness.
Akhatar [19] stresses and I join his concept, that "generosity is not restricted to giving. It also involves accepting people as they are and having a charitable view of their motives. The affect associated with generosity is that of tenderness. Generosity thus represents the "affectionate current" Freud [33] of love" [19]. Furthermore, Aktar states that generosity might be inherited while "Melanie Klein [34] traced the origin of generosity to the establishment of a good internal object: "Inner wealth derives from having assimilated the good object so that the individual becomes able to share its gifts with others. This makes it possible to introject a friendlier outer world, and a feeling of enrichment ensues. Even the fact that generosity is often insufficiently appreciated does not necessarily undermine the ability to give" [19,34]. I think that genuine "giving" births from the parental recognition and relatedness to their child's separateness (even from his birth), their skill to love him and accept him as he is [1,14].
The controlled constipation might be expressed later in life by the pleasure to long term investments, the need to extensive economization of money [35], the satisfaction of retaining and saving or difficulties to throw unnecessary material (symbolization of constipation), holding onto objects, obsessive behavior and even verbal constipation. Yet, we have to remember that these symptoms might be considered as normal especially when the toddler can control them. They are abnormal when the symptoms control or overrule the individual.

Pathological constipation might, in my view; lead to what
Aktar pointed it to "chronic stinginess, miserliness, niggardliness, penuriousness, tight-fistedness or small-heartedness …. The miser seems to be saying to them, "Why should I give you anything when I myself have not been given much?" This brings up the fact that while anal-drive derivatives are clearly discernable in it [36,37], "monetary constipation" is, at its bottom (pun unintended), a reaction to early oral deprivation. The miser has experienced a profound and traumatizing lack of nourishment from his early caretakers and, in a move typical of "identification with the aggressor" [38], has adapted an ungiving attitude toward others" [19].
Emanuel [39] focuses in his paper on "the role of therapeutic work in facilitating the move from 'holding onto' a concrete object (e.g. faecal retention), towards the process of introjection of a containing internal object, through the process of maternal 'reverie' [40]: feeling held in mind" [40]. Emanuel stresses also another aspect of the pathological constipation, by relating to the need of the infant "to hold onto the object as a matter of survival seems to be linked to the faecal retention of the toddler" [39]. He relates this 'holding on' to the object, in the possible absence of adequate parental containment in early infancy [39]. Emanuel describes "brief family work where a child was holding onto her faeces for up to eight days and where her difficulties seemed related to a fear of loss of the object, anxiety about separation, abandonment and falling into a 'void', which Bion described as 'the domain of the non-existent' [39,41]. Furthermore, Emanuel elaborates another source of pathological constipation which relates to symbolization between defecation and baby's birth. His constipated patient told her pregnant mother that she "'couldn't poo because her baby would come out!'" and he reminds us that Freud already in 1909 pointed out "the equation of faeces with babies, as in the Little Hans case history' [42]. This same symptom -note Emanuel and I join his notation -"can also be an expression of a defence …. Against a fear of losing all the body contents along with the faeces'" [39].

Example of Constipation that can be Considered as Normal
Anna (2 years and 10 months) restraining unconsciously her waste in order to feel strong and captivate her mother's worriedness (passive aggressive), yet she can master her constipation up to her stomach pain and then evacuate under her control. Anna says to her mother (pregnant in her 8 months) who is worried about her constipation: "You don't understand, mummy, I like to feel full in my belly. When I am full I am strong and when I am empty I am weak. Do you feel the same when you are full with the baby in your stomach?" Through constipation Anna control her body's fullness, identification with her mother but also control her mother's worry in a passive way (it is she (Anna) who suffers from constipation) that hide her aggressiveness (passive aggressive).
Through the mother's description of the situation, I was impressed that Anna has a normal emotional development and I shared my impression with the mother. We could work together how and to avoid struggling with Anna about going to toilette, in order to sooth Anna's passive aggressive relations. The mother planned to prepare special food that will help Anna to evacuate in the moment she will choose. We also searched possibilities to allow Anna to express her aggression in words so that she will not need her passive aggression expression. This was very difficult task for the mother who can't tolerate her children's aggression. They also fill bags with little toys and empty bags with pleasure, they played with the dolls as if being pregnant, having a baby. Finally, after four days of constipation Anna's normal needs to protect her body emerged accompanied by her stomach pressure to ex-pulse her waste: This urge was stronger now than her other needs to restrain, avoid emptiness and control her mother . Hence, Anna, according to her own will decides to go to the toilette and to empty her belly. She discovers her enjoyment of defecation and an unconscious new control over her mother: She goes to the bathroom just when the mother rushes to her work and thus she makes the mother restrain (her anger) and her walking to work and wait patiently until Anna is fished empty. They hugged warmly each other.

Example of Tendency to Chronic Constipation
This form of constipation reflects an uncontrolled constipation doesn't reflect the passive aggressive defence, but a defence against anxiety. Ben (two-year and ten months) restrains also his waste but he is in a different emotional state. He is unconsciously forming constipation as a symptom which "serves" him as a defense against anxiety. Ben keeps close his mother who is anxious for him and thus he controls her proximity and avoids the anxiety of abandonment. Unlike Anna, who nurtures her body and controls her constipation as well as her emptying with enjoyment, Ben does not control his constipation. His symptom over-rule himself and it is getting worse. Ben is not emptied for six days. He feels the pressure in the stomach, but he is not aware of its connection to constipation. Mom is very anxious. She is trying to convince him to poop, even frightening him that soon he will burst like the ground is shaky and burst, but nothing helps. All his mother's frightening only increases his unconscious anxiety that Mom might abandon him and attach to his brother if she will not be worried for him. Mother decided to try and heal him by laxatives capsules. She tells Ben that she wants to see if he has wounds there in his poo, and she doesn't prepare him to the penetration of capsules. She was afraid that he will refuse the capsules. Ben is experiencing the laxatives capsules as penetration, as a rape, a physical harm and abuse. When laxatives cause him diarrhea, he feels as if his bodily productions are evacuating away from him and he is empties uncontrollably. Ben reacts by panic. As if he experiences anxiety of abandonment not only toward his mother but also toward his bodily productions.
Following this experience of forced penetration and the diarrhea, Ben returns to a chronic constipation, gets progressively worse which lasts for many days. The mother consults a physician who proposes to use enema, and the mother do it once again without explaining and preparing Ben to cooperate with her treatment. It is as if she doesn't recognize that after all, it is his body! Ben subjective experience is again of rape and invasion into the body, it hurts him, leaving him empty and damaged. He lost power, and this time he is sinking into depression, withdrawn with a pacifier in his mouth and refuses to play, to eat or to participate with his parents.
Following his depression, the mother consults me as a psychologist. Due to his young age, and his traumatic experiences I decide to take care of him through his parents; First I reassure them that Ben will overcome his constipation but that we have also to recreate his trust in his parents that they will respect his separateness, his unique needs of mastery on his body, that nobody will touch his belonging without his permission. The mother discloses resistance to cooperate with me. She doubts whether he really could overcome his constipation. She is hurt and injured every time Ben refuses to go to the toilette. She doesn't understand his feelings of penetration and rape as she did it for him with so much love. I try to trigger the mother's trust in me with the help of the father who is very passive in the room. I propose them to give one week of working together, not telling Ben a word of toilette or constipation. Giving him good food that might help the evacuation when the day will come, and if they will see a little change after the first week we will continue together, if not we will separate. I guide the parents to play with Ben with clay, plastering and gouache, create symbols to his bodily productions, to propose Ben to do collections of little toys in package and then to play through empting the package only by his permission; to keep with respect his creations even if it seems to the mother that it is dirty. Hence, to give him back the sense of mastery on his body, the sense that he is loved as he is, and symbolization of restraining and evacuation.
To my surprise, at this point the father suddenly became present in the room. As if he identified with his son who will have permission to have back his autonomy; from then on the father helped all of us a lot to enable Ben to regain autonomy and trust. The bonding between father and Ben -flourishes; the father says it is the first time that he has such bonding with one of his children. Ben expresses prides with his creations, parents are happy with him but the mother feels now abandoned by her husband and child. The constipation's symptom served as a reflection of the family psychodynamic problems. The father decides to keep on working with me and mother couldn't refuse. After one week more, Ben slowly began to evacuate his waste. He had still pains but with the appropriate food he could gradually overcome his pains and evacuate under control his waste.

Conclusion
The symptom of constipation of both children may seem similar while the origin of this symptom is rather different: Anna uses it as aggression (passive aggressive) toward her mother as a defence against her mother's intolerance of aggression while she protects well enough her body; While Ben uses the constipation's symptom as a defence against his anxiety of abandonment.