Clinical Reference Systems: Pediatric Advisor 10.0
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Description

Children who refuse to be toilet trained either wet themselves, soil themselves, or try to hold back their bowel movements (thus becoming constipated). Many of these children also refuse to sit on the toilet or will use the toilet only if a parent brings up the subject and marches them into the bathroom.

Any child who is over 2-and-1/2 years old, healthy, and not toilet trained after several months of trying can be assumed to be resistant to the process rather than untrained. Consider how capable your child is at delaying bowel movements (BMs) until he or she is off the toilet or you are on the telephone. More practice runs (such as you used in toilet training) will not help. Instead your child needs full responsibility and some incentives to spark his motivation.

The most common cause of resistance to toilet training is that a child has been reminded or lectured too much. Some children have been forced to sit on the toilet against their will, occasionally for long periods of time. A few have been spanked or punished in other ways for not cooperating. Many parents make these mistakes, especially if they have a strong-willed child.

Helping Your Child with Daytime Wetting or Soiling

Most children less than 5 or 6 years old who have BMs in their pants or wet their pants and have no symptoms of illness are simply engaged with you in a power struggle. These children can be helped with the following suggestions. If your child holds back bowel movements and becomes constipated, medicines will also be needed, so first talk with your child's physician. (For further information, see Soiling with Constipation. ) If your child also wets the bed, work on the daytime wetting first because it will be much easier to change.

1. Transfer all responsibility to your child.

   Your child will decide to use the toilet only after he realizes that he has nothing left to resist. Have one last talk with him about the subject. Tell your child that his body makes "pee" and "poop" every day and it belongs to him. Tell him that his "poop" wants to be in the toilet and his job is to help the "poop" come out. Tell your child you're sorry you punished him, forced him to sit on the toilet, or reminded him so much. Tell him from now on he doesn't need any help. Then stop all talk about this subject. When your child stops getting attention for not using the toilet, he will eventually decide to use the toilet for attention.

2. Generally stop all reminders about using the toilet.

   Let your child decide when he needs to go to the bathroom. Do not remind him to go to the bathroom and do not ask him if he needs to go. He knows what it feels like when he has to "poop" or "pee" and where the bathroom is. Reminders are a form of pressure, and pressure doesn't work. He should not be made to sit on the toilet against his will because this will foster a negative attitude about the whole process.

   Some children have never used the toilet and in the beginning will need a pleasant reminder once a day when they are clearly holding back. You can say, "Do you know how you can make your tummy feel better? After your tummy gets rid of the poop, it will feel good." However, don't go with your child into the bathroom or stand with him by the potty chair. He needs to get the feeling of success that comes from doing it on his own and then finding you to tell you what he did.

3. Give incentives for using the toilet.

   If your child stays clean and dry, he needs plenty of positive feedback, such as praise, smiles, and hugs. This positive response should occur every time your child uses the toilet. If a child soils or wets himself on some days and not others, reward him only when he is clean for a complete day. On successful days consider taking 20 extra minutes to play a special game with your child or take him for a walk to the playground. Sometimes special incentives, such as favorite sweets, can be invaluable. One of your main jobs is to find the right incentive. For using the toilet for BMs, initially err on the side of giving him too much (for example, several sweets each time). If you want a breakthrough, make your child an offer he can't refuse.

   Incentives work best if they are special and not available as rewards for other tasks or as a part of daily life. Additional motivation can come from making a carefully orchestrated "fun trip" to the preschool. Clarify for the child that regular preschool attendance requires toilet training.

4. Give stars for using the toilet.

   Get a calendar for your child and post it in a conspicuous location. Place a star on it every time he uses the toilet. Keep this record of progress until your child has gone 2 weeks without any accidents.

5. Make the potty chair convenient.

   Be sure to keep the potty chair in the room he usually plays in. This gives your child a convenient visual reminder about his options whenever he feels the need to urinate or have a BM. If your child has been wetting his pants, the presence of the potty chair and the promise of treats will usually bring about a change in behavior. If your child has been having bowel movements in his pants, he may need a pleasant reminder only when he is clearly holding back. You can say, "The poop is trying to come out and go in the toilet. The poop needs your help." Tell your child that you want sitting on the potty to be lots of fun. What would they like to do? A few children temporarily may need treats for simply sitting on the toilet and trying.

6. Diapers, Pull-ups, or underwear.

   Whenever possible, replace Pull-ups or diapers with underwear. Help your child pick out some underwear with characters on it that "don't like poop or pee." This usually yields the correct decision on the part of the child. Even if your child wets the underwear, keep with the plan. If your child holds back BMs, allow selective access to diapers or Pull-ups for BMs only.

7. Remind your child to change his clothes if he wets or soils himself.

   As soon as you notice that your child has wet or messy pants, tell him to clean himself up immediately. The main role you have is to enforce this rule. If your child is wet, he can probably change into dry clothes by himself. If your child is soiled, he will probably need your help with cleanup. If your child refuses to let you change him, ground him until he is ready.

8. Don't punish or criticize your child for accidents.

   Respond gently to accidents, and do not allow siblings to tease the child. Do not put your child back into diapers unless he is taking laxatives or stool softeners. Punishment or criticism will only delay successful training and it could cause some emotional problems.

9. Ask the preschool or day care staff to use the same strategy.

   Ask your child's teacher or day care provider to let your child go to the bathroom any time he wants to. Keep an extra set of clean underwear at the school or with the day care provider.

Call Your Child's Physician During Office Hours If:

• Your child holds back his bowel movements or becomes constipated.
• Pain or burning occurs when he urinates.
• Your child's resistance has not improved after you have followed these suggestions for 1 month.
• The resistance has not stopped completely after 3 months.