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When he was 2 years and 8 months old, Sam presented with the symptom of stool retention. After a series of consultations with the parents and with Sam, he began five-times-per-week treatment.
Sam's mother described him as difficult to soothe and very sensitive from birth. She nursed him for the first few months. From the time he began to eat solids, he was and has remained a picky eater. All his developmental milestones were normal. Sam had the same nanny from his early weeks until he was 2 1/2. Toilet training was initiated by the caretaker when Sam was 2. When the mother felt that the nanny was too rough and punitive about the toilet training, she decided to abandon efforts to toilet train Sam until he was a little older. Constipation began soon after these initial efforts at training by the nanny. Sam was treated with suppositories and a mild laxative. The nanny left abruptly a few months later, after which symptoms of constipation became more severe, and conscious efforts to retain his stool began.
When I met Sam, he was an adorable, serious little boy on the cusp between babyhood and childhood. He was precocious in verbal and fine motor skills, which allowed him a lot of self-expression in the treatment for his age. He separated easily from his mother in the first session; he made eye contact with me, and as he got to know me he often wanted to be very close to me. Sam seemed to want the new relationship and the chance to talk about his problems.
In the initial consultations and in the first year of treatment, Sam continued to seem connected and trusting; from the beginning he often wanted to play (it seemed symbolically) with small vehicles. He played getting stuck,