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“Help! My three-year-old refuses to poop on the potty!”

This is a common complaint heard by pediatricians. The three- to four-year-old has successfully toilet-trained for urination and may even have had some success with stooling in the toilet, but when it is time for a bowel movement, a child may either requests a diaper, hides in a corner, or becomes an expert at “holding it in”. We call this condition Stool Toileting Refusal. These children completely understand what is expected and demonstrate the ability to control their urine and stool but just refuse to “poop on the potty”.

On average, children are fully daytime toilet trained between the ages of two and a half to three and a half years of age. A 2004 study showed that about a quarter of young children develop Stool Toileting Refusal. Please note that Stool Toileting Refusal (which is a behavior seen in children younger than four years of age) is not the same as encopresis (a similar condition seen in older children that you should discuss with your pediatrician). This article will review precautions, potential causes that you can be aware of to prevent the problem and solutions for those that are already in the midst of this.

Precautions

It is important to see your pediatrician if there is any rash around the anus (sometimes caused by a bacterial infection that causes pain with stooling and requires treatment before you can address the behavior) and to make sure that your child does not have impacted stool. Know that girls who hold their stools are also at increased risk for bladder infections.

Until the problem is solved, DO allow your child to use diapers for poops. This is critical to prevent stool holding, which leads to impaction and stretching of the large intestine and long-term problems. Be understanding and supportive. Tell your child, “You may just not be ready to use big kid underpants yet. That’s okay.” Some children may need reassurance that it’s okay to poop in a diaper until they learn how to use the toilet.

What Is Your Child Thinking?

There are several recognizable patterns in children with Stool Toileting Refusal.  It is wise to figure out which one fits your child because the approach is different for each.

The Fearful Ones

  • Fear of falling in:Your child may have experienced slipping on a regular toilet seat too big for their little bottom or they may fear the scary flush in public restrooms. Their logical solution is to avoid the experience. For these children, make sure that the potty chair is firmly planted on the ground, then practice desensitizing to reestablish a pleasant feeling about the toilet or potty chair. Begin by having your child sit on the potty with clothes on a few times a day and reading books (this works well right after meals and before bedtime). As your child becomes comfortable with this, gradually shift to sitting on the potty with just a diaper and then without the diaper. Use a sticker chart or other small reward for each successful step. Do not pressure. Bring sticky notes to public restrooms to cover the electric eye.
  • Fear of losing the penis:While this sounds silly to adults, it is often a real fear for preschool boys who are just figuring out the differences between boys and girls at the same time that they are working on potty-training. They see that the girls have “lost” theirs and they do not yet understand object permanence. They have seen the poop “disappear” down the toilet. Let your son know in advance that his penis cannot fall off in the toilet.
  • Fear of losing the poop:These children have worked so hard to create this precious gift that you requested, only to see it disappear down the toilet to never return. For these children, it helps if you teach them early that all poop “likes” to go down the toilet to be with the other poop. Let them actually “see” that yours goes there. Tell them that poops that have touched a diaper or underwear don’t get to “hang out” with the other poop down there; only those that have been passed into the potty seat or toilet do.  Pediatrician Barbara Howard calls this “The Poop Party under the house”. Remember that this is preschool thinking. Some children instead fear letting their stools go because they don’t know where water from the toilet goes. For these mechanically minded kids, explore the toilet and its pipes to increase your child’s sense of control.
  • Fear of punishment:Some children may have been forced to sit on the toilet against their will, possibly for long periods of time. Others may have been spanked or punished in other ways for not cooperating. Many parents make these mistakes, especially if they have a strong-willed child. The child rarely fears the toilet itself but rather what might happen again in the bathroom. If this has happened, tell your child that you are sorry and that it won’t happen again and make it so. Then work on desensitizing as discussed above.

 

The Power Hungry with Control Issues

Potty training occurs at the same time as most kids start to gain control over their emotions and actions. This is a big and very important job. Respect their need to do things on their own and be available when they ask for help. Let your child gain confidence and self-esteem in areas other than potty training (cleaning the table, feeding the pet, etc.) and offer your child reasonable choices through the day (“Do you want your milk in the red cup or the blue cup?”). Avoid practice runs, reminders and lectures to use the toilet after three years of age which increase power struggles related to stooling.

If you find yourself in this situation, it’s okay. Just back off of potty training and put your child back in diapers all day and let your child take over. Your child will always be the boss of his or her poop and will tell you when they are ready to use the potty. You, however, are the boss of big kid underpants which are a privilege to be earned for these children. Do not use pull-ups. You might even want to use cloth diapers as they are less comfortable when wet or soiled. Know that these children may also revert to urinating in the diaper which is fine for now. Do not criticize or punish and do not allow siblings to tease about this. Parents must show no emotion when the child dirties or wets the diaper and should not immediately focus on changing it. Instead, wait a few minutes and then clean the child silently and with little or no interaction. This is important to remove any positive reinforcement that stool refusal was providing the child.  We refer to this a secondary gain (generally getting the attention of the parent for an unwanted behavior).

Some of these children may also need additional intervention. Start by reducing the number of total demands you give this child each day, but absolutely follow through on those you do give by physically moving the child to do the task after the first request, again with no emotion. Do not repeat yourself. In some families, it may help for there to be a small reward or sticker for other family members who successfully poop in the toilet that the child can also earn for the same behavior with no fanfare.

It is very important that all parents/caregivers are approaching the issue in the same fashion. Family tensions may make things worse.

Constipation

It is likely that constipation was either a trigger for the Stool Toileting Refusal or a result of the refusal. It is very important to minimize any further painful bowel movements and helpful for your child to have at least one to two stools daily. To accomplish this, give a daily laxative to help move the stool along until the problem is resolved for at least a few weeks. Your pediatrician can give you specific laxative recommendations for your child. The dose is then adjusted until there is at least one normal sized stool every day (size of a small banana). Some children will only pass small hard stools which does not solve the underlying problem. Make sure that your child drinks plenty of water, limit dairy products to two servings daily and increase high fiber foods (at least 5 grams plus their age in years= 7 grams for two-year-old*). Encourage lots of physical activity.

Generally, the approaches above will work within a few weeks. If not, be sure to discuss with your pediatrician.

When your child does finally ask to use the toilet on his or her own to stool, make sure that you remain indifferent.  A simple “If that’s what you want” will suffice. There should be no prizes or outward celebrations for this expected behavior (though parents are certainly welcome to celebrate on the inside!).

* High fiber foods: Peas, beans, broccoli, apricots, peaches, pears, figs, prunes and dates, pineapple, sweet potatoes, popcorn if over 3 years, raw tomatoes, whole wheat or bran bread and bran muffins, ground flax seed.

For more information, visit www.essehealth.com.

K_NortonBy Dr. Karen Norton, Esse Health Pediatrician
9930 Watson Road, Suite 100
St. Louis, MO 63126
Phone: 314-965-5437

Resources:

http://www.mayoclinic.com/health/high-fiber-foods/NU00582

http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000193.htm

Taubman B: Stool toileting refusal: a prospective intervention targeting parental behavior. Arch Pediatr Adolesc Med. 2003 Dec;157(12):1193-6.

Taubman B: Toilet training and toileting refusal for stool only: a prospective study. Pediatrics. 1997 Jan;99(1):54-8.

Schmitt B: Toilet Training Problems: Underachievers, refusers, and stool holders. Contemporary Pediatrics 2004

Howard B: Behavioral Consult: He just won’t poop. August 2013. www.pediatricnews.com