Toilet Training Resistance

Children who refuse to be toilet trained either wet themselves, soil themselves, or try to hold back their bowel movements (thus becoming constipated).  Any child who is over 30 months old, healthy, and not toilet trained after several months of trying can be assumed to be resistant to the process rather than untrained.  They know how to use the potty, but elect to wet or soil themselves.  Most children who are resistant to toilet training are enmeshed in a power struggle with their parents.   The most common cause of resistance to toilet training is that your child has been reminded too much.  Your child now needs full responsibility and some incentives to re-spark his motivation. 

Ways to help your child:

1. Transfer all responsibility to your child.  Your child will decide to use the toilet when he realizes he has nothing left to resist. When your child stops receiving conversation for nonperformance he will eventually decide to perform for attention.
2. Stop all reminders about using the toilet.  Let your child decide when he needs to use the bathroom, stop all reminders.  He knows what it feels like when he has to "poop" or "pee" and where the bathroom is.
3. Give incentives for using the toilet.   Positive feedback includes praise, smiles and hugs every time the child uses the toilet.  You can also use stars on a calendar for every time they use the toilet.  When they have achieved a set number of stars they will receive a special incentive (a movie, video time, special toy or extra time with you).  There are four rules that make incentives powerful:  the incentive is something the child strongly desires, it is given immediately after the child releases urine or stool into the toilet, the child is given access to the incentive for 30 to 60 minutes, the parent continues to own and control the incentive.  The last requirement is essential.  Access to a bike, costume, video or whatever is time-limited.  In essence, the child earns a privilege, not another possession.
4. Remind your child to change himself if his clothes are wet or he soils himself.  You may need to help if he soils himself, but keep him involved in the process.  He may not like the clean up and be motivated to keep his pants clean.
5. Don't accompany your child into the bathroom or stand with him by the potty chair, he needs to do this on his own.

Bowel training resistance with normal bowel movements

Children who are bladder trained but have delayed bowel control wear underwear all day but ask for a diaper or a pull-up when they need to pass bowel movements.  Some wait to pass bowel movements until they are put to bed in a diaper for a nap or at bedtime.  All of them have excellent bowel control and need no additional toilet training. Use the above toilet training resistance approach with one of the following three techniques:

• Have the child go bare bottom for a weekend.
• Withhold diapers and pull ups.  The parent should tell the child the parent has run out of them or that the doctor said the child doesn't need them anymore.  Keep the child in regular underwear.
• Withhold underwear.  If the child likes to wear underwear, keep the child in diapers all the time.  Many older children become upset about going to preschool in diapers and quickly become bowel trained.  The disadvantage of this approach is that some children stop trying to stay dry.  Another variation is to start the day in underwear but if he soils the underwear, he's back in diapers.  If he goes poop into the toilet, he's back in underwear.

These techniques run the risk of converting the nonbowel-trained child into a stool holder.  

Bowel training resistance with stool holding

These are children who hold back bowel movements because they think they can "turn off" bowel movements forever.  The standard explanation for stool holding is that the child is trying to avoid pain associated with the passage of bowel movements.  The treatment steps include:

• Use of Miralax daily to soften stool.
• Clarify with the child that "the poop wants to come out every day".  The child's job is to help the poop come out-it doesn't matter where, diaper or toilet.  Reassure him it won't hurt anymore to" pass poops".  Remind him that the way to prevent stool leakage is to release a poop every day.
• Allow access to pull-ups or diapers for bowel movements only.  The goal is to prevent stool holding, impaction, and stretching of the large bowel that stool holding may cause.  Reassure children it is okay to go poop in diapers until they learn how to use the toilet.
• Provide incentives for release of bowel movements.  They should receive a much larger incentive for release into the toilet than for release into a diaper or pull-up.
• Add disincentives for stool holders.  A disincentive is removal of a possession or privilege until a behavior improves.
• Use targeted reminders when necessary.  The harm from stool withholding outweighs the harm from reminders after two or three days without a bowel movement.  Children need to be grounded if they are leaking stool or haven't had a bowel movement at the end of two or three days.  Grounding means they are restricted to their bedroom with access to the bathroom.  Tell them leakage always means there is a big poop inside trying to get out.  Once a normal or large-sized poop is released he is released from grounding.
• Keep track of stool output.  Some stool holders release a bowel movement every day but it is a small one.  Stool is still retained and impaction can occur.  The goal is to get the child to release a normal-sized stool every day.  The parent must see the stool before it is flushed and record the size on a "Good Pooper" progress chart.  Normal stools are arbitrarily defined as 6 to 10 inches (a small banana) every day.

~Barton D. Schmitt, MD