Toilet training done badly can lead to medical complications, including dysfunctional voiding, constipation and impaction-and even child abuse. This article describes in detail how to treat toilet training problems before they cause harm.

Toilet training can be defined as delayed if the child is over 3 years of age, has normal development, and is not toilet trained after three or more months of training. (This definition excludes families who have not yet started toilet training.) Usually the delay is in bowel training. Taubman found that 22% of bladder-trained children were not bowel trained one month after completing bladder training.' [For information on toilet training basics, see "Toilet training: Getting it right the first time," in the March issue, accessible at wwwcontemporarypediatrics.com. ]

Although the Diagnostic and Statistical Manual for Primary Care Child and Adolescent Version uses 4 years of age as a cutoff for abnormal toilet training delays, it makes sense to evaluate delays at 3 years of age to prevent ongoing harmful approaches by parents. If the parents are mishandling toilet training problems, it's a mistake to allow them to continue to do so for an additional year before intervening. If, for example, parents are punishing the child for noncompliance or forcibly holding the child on the toilet, these negative interactions will be much harder to undo and repair with time. Calling delays abnormal can wait until 4 years of age, but evaluation and intervention should begin sooner.

Differential diagnosis of toilet training delays

Toilet training delays have several causes, both behavioral and organic. The cause is most often behavioral. Organic causes are rare. Questions about neurologic causes arise often, but if the child can postpone urinating or defecating or hide to do it, neurologic input is clearly intact.

The most common organic cause of isolated daytime wetting is a urinary tract infection. Other causes to consider are bubble bath urethritis, giggle incontinence, urgency incontinence, or an ectopic ureter. Indications for pursuing these diagnoses are, respectively: dysuria, wetting during laughter, wetting while running to the toilet, or constantly damp underwear. Children with diarrhea or constipation during toilet training also need a medical evaluation. A hallmark of children with an organic cause for delayed toilet training is that they try very hard to use the toilet (they run to the bathroom, for example).

Children with delayed toilet training require a careful workup to help individualize the treatment plan. In general, the workup is mainly historical and the physical examination is not very beneficial except for detecting unreported constipation. One of the most important facts to determine is whether or not the child will sit on the toilet. If he will, does he do it spontaneously, only with reminders, when restrained by the parent, or with threat of punishment? If the parent uses physical punishment, examine the child for evidence of physical abuse.

Toilet training resistance

The most common cause of delayed toilet training is resistance or refusal. This entity was first described in depth in 1987 and elaborated in several subsequent articles. Resistant children are older than 3 years and know how to use the potty but elect to wet or soil themselves. They have nonretentive encopresis and diurnal enuresis. Most of them never sit on the toilet spontaneously, and many decline to sit on the toilet when the parents prompt them to do so.

Most children who are resistant to toilet training are enmeshed in a power struggle with their parents. The cause of the power struggle is usually reminder resistance-an oppositional response to excessive reminders to sit on the toilet. In addition, most resistant children have been held on the toilet against their will. The child's contribution to the power struggle is usually a difficult, strong-willed temperament.

Treating toilet training resistance

The "Guide for Parents: Toilet training resistance," at the end provides detailed instructions on how to get a resistant child back on track. Steps that the physician can take in the office to motivate a resistant child include the following:

Transfer all responsibility to the child. Tell the child that it is her body, and "the pee and poop belong to you." Tell her that she doesn't need anybody to help her anymore, that it's up to her.

Ask the parents to stop all reminders to use the potty. Reminders and practice runs are what keep the power struggle going. Children older than 3 years never need reminders to help them become toilet trained. Make the child think that using the toilet is her idea.

Brainstorm incentives. Once the power struggle has been dismantled, parents need to come up with the right incentive to achieve a breakthrough. Many parents have a defeatist attitude about incentives and think they have exhausted their options. They say things like "She has so many toys that she won't work for anything new" or "She doesn't care if we take things away."

Four rules make incentives powerful:

The incentive is something that the child strongly desires. Ask for the child's input: "What would help you remember to look after your poops?"

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, videotape, remote-control car, paint set, or whatever, is time-limited. In essence, the child earns a privilege, not another possession. That's the only way to maintain the value of the incentive.

The "Guide for Parents: Using incentives to motivate your child," at the end of this, should be given to parents who have a child with any type of toilet training delay. It also can help treat children with any other deliberate behavior problem, such as bedtime resistance, whining, or trichotillomania.

Direct most of your comments to the child. By talking with the child about her problem, the physician makes it clear who is accountable for improvement ("ownership of the problem"). If the child doesn't communicate, sit close to her, establish eye contact, and make some suggestions. At the end of a visit, say "Now tell me again, what is your job?" and expect the child to answer, "to get the poop in the toilet" or "to run to the bathroom if the poop starts to come out."

Give the child a chart for recording progress. Tell the parents that stars or special stickers should be placed on the chart for every passage of urine or stool into the toilet. Separate charts for pee and poop tend to work best. Once the child becomes partially bladder trained, the pee sticker can be given for staying dry all day.

Provide follow-up visits. See the child for follow-up visits (usually monthly) until she shows improvement. Make it clear that you want her to bring the star chart on the next visit, so that "I can see how many stars you have." Review the calendar seriously. If the child has improved, praise her with words, applause, a hug, lifting her up high, or a thumbs-up sign. Say "Keep up the good work." If improvement is marginal, tell the child to "listen to your body better." Let her know you are on her side by saying things like "I'm sorry you messed your pants, I know you want to do better." If she's not doing well, ask questions such as "What should we try next?" Try to accentuate the positive.

Recheck on reminders with parents. Many parents continue giving reminders long after they have promised to discard them. As long as reminders continue, the control battle will rage on. Review reminders on every visit. Emphasize that reminders come across as nagging and will not suddenly become helpful.

Bladder training resistance

Most children older than 3 years who are not bladder or bowel trained can be bladder trained fairly quickly. The bladder reaches capacity four to eight times a day, so the child has many opportunities to elect to urinate into the toilet. Also, the micturition urge is a much stronger signal than the defecation urge. Another good reason to deal with bladder training first is to reduce numerous reminders to use the toilet for urine, which fuel bowel training resistance.

First, the parent must discontinue diapers and pull-ups except for bowel movements. Then comes the crucial step: Once the child understands how to use the toilet, the parent must stop all reminders to pee. Even if the child is dancing around trying to hold back urine,

the parent must not comment. More than 95% of children cannot hold back urine, and they will stop this behavior only if it is ignored. Children usually don't like wetting their underwear and selftrain for urine in a matter of days. If not, a bare-bottom day, as described in the next section, can be scheduled.

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 pull-up when they need to pass bowel movements. Some of them 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.

Most of these children are easy to treat using the toilet training resistance approach combined 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 that the parent has run out of them or that the doctor said the child doesn't need them anymore, then keep the child in regular underwear.

Withhold underwear. If the child likes to wear underpants, the parent should 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 have the child 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. If that happens, have the parent add a laxative to the child's regimen and continue full-time diapers or underwear (whichever the child dislikes most). If the child doesn't start using the toilet, advise the parent to again give the child selective access to diapers for bowel movements and consult the "Guide for Parents: Stool holding: When your child holds back bowel movements and is not toilet trained" .

Bowel training resistance with stool holding

The hardest children to treat are those who hold back bowel movements. Many of them believe that they can "turn off" stool production forever. They think the poop will somehow disappear. The standard gastroenterologic explanation for stool holding is that the child is trying to avoid pain associated with passing bowel movements (primary pain avoidance). The standard behavioral pediatrics explanation is that the child is withholding bowel movements from his parents who want them. Another reason that I encounter often is that the child is trying to keep his poops inside to prevent leakage-a major misunderstanding on the child's part. Most children have to be 5 years of age cognitively before they can understand that stool accumulates and that the more they hold back, the more they will leak. In some cases, all three factors contribute to stool holding.

All stool holders need to be evaluated to be sure they don't have a physical cause, such as streptococcal perianal cellulitis. They also need to be checked for an impaction, which requires a bowel cleanout. Some of them also have become dysfunctional voiders, which has its own set of complications. Girls with dysfunctional voiding often have recurrent urinary tract infections, for example.

The main goals for treating stool holders are: 1. Remove the impaction and relieve constipation, 2. Give the child reasons to use the toilet, and 3. Dismantle the power struggle. The treatment steps are as follows:

Prescribe a laxative. Stool holders usually don't respond to stool softeners alone." They need a daily stimulant laxative (senna product) to amplify their rectal signal and to help propel the stool along its way. In my experience, compliance and success are highest with products formulated in chocolate-flavored chewable squares, such as Ex-Lax, which contains 15 mg of sennosides. Dosage for this product is ¹/₂ to 1 square for children 3 to 5 years of age, 1 to 2 squares for children 5 to 12 years, and 2 squares for teenagers, given once a day at dinner or bedtime. The endpoint is one or two normal-sized soft bowel movements a day. Our job is to titrate various medications until we achieve this stool pattern. If the child gets into control struggles over taking medicines containing senna, prescribe polyethylene glycol (Miralax), an osmolar laxative. While somewhat less effective, it's colorless, tasteless, odorless, and texture-free and works when added to the child's favorite fluid.

Clarify the goal for the child. Review 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 that it won't hurt anymore to "pass poops." Remind him that the way to prevent stool leakage (which older children greatly dislike) is to release a poop every day.

Allow access to pull-ups or diapers for bowel movements only. Many children withhold bowel movements when parents withhold diapers and pull-ups. Keep the child in underpants so the he will maintain bladder control. But allow the child to use diapers or pull-ups for poops if he so chooses. The overriding goal is to prevent stool holding, impaction, and stretching of the large bowel that they cause. Many children need to be reassured that it's okay to go poop in diapers until they learn how to use the toilet.

Provide incentives for release of bowel movements. Have the parents give the child an incentive for the release of all bowel movements. They should give a much larger incentive for release into the toilet than for release into a diaper or pull-up ("differential incentives"), as described in the "Guide for Parents" on stool holding.

Add disincentives for recalcitrant stool holders. A disincentive is the removal of a possession or privilege until a behavior improves. Some strong-willed children will not give up their testing behaviors to obtain incentives, especially if they are spoiled materially. These children need a disincentive added to their treatment program. (Exception: unhappy, depressed, or angry children who need referral for counseling.)

The most powerful disincentive I've found is to put the child into a video-free world. That means no access to television, videos, or computer games until the child learns how to use the toilet or potty for bowel movements. Parents can substitute much physical affection and parent contact. For every normal-sized bowel movement the child releases into the toilet, he receives two hours access to TV, videos, or the computer. Otherwise all TV and video viewing occurs in a closed room that only poop trained children have access to. This keeps the child's siblings from becoming upset.

A variation is to start each morning with the TV off. The only way for the child to get it turned on is to pass a normal-sized bowel movement into the toilet. It sometimes helps to remind the child that "you are the boss of the poop," but "your parent is the boss of the TV"

In my experience, the average child responds within one to two weeks to incentive and disincentive programs used simultaneously, and even recalcitrant stool holders respond within two months. When the child starts complaining or crying that he can't watch his favorite videos, it means we're making progress. Harmful behaviors such as stool holding sometimes require drastic measures. I always tell the parents to tell their child that they're sorry, but Dr. Bart said that only kids who go poop in the potty can watch TV This keeps the parent in the role of the child's ally. Children can usually be given age appropriate access to TV and videos after they demonstrate bowel control for one month.

Use targeted reminders when necessary. I've emphasized repeatedly that practice runs and reminders to use the toilet are the main cause of power struggles and should be avoided after 3 years of age. While this admonition also applies to stool holders, the harm from stool holding outweighs the harm from reminders after two or three days without a bowel movement. Persistent or recurrent constipation perpetuates bowel distention and painful bowel movements. Children need to be reminded to use the toilet and grounded until they do so when they are leaking stool or reach the end of two or three days without a bowel movement.

Grounding means the child is restricted to his bedroom with access to only one room, the bathroom. I call this "poop jail," which keeps the intervention on a humorous level for most children. They are told that "leakage always means there's a big poop inside trying to get out." While this approach brings initial protest, it usually leads to the desired result. The child is released from "poop jail" as soon as he produces a normal or large-sized poop. A more drastic approach that I occasionally use is to restrict the child to the bathroom and inform him he can't come out until he produces a normal-sized poop.

Keep track of stool output. Some stool holders release a bowel movement every day, but it's a small one. Stool is still retained and impaction recurs. The goal is to get the child to release a normal-sized stool every day. To this end, the parent rewards the child for normal-sized stools. For the system to work, the parent must see stools before they are flushed and record the size of the total stool on a "Good Pooper" progress chart. I ask the parent to guess at a number in inches that describes the composite stool and record it next to the star or sticker on the chart. Normal stools are arbitrarily defined as 6 to 10 inches (a small banana) every day.

Toilet avoidance or phobia

The child with toilet avoidance won't sit on the toilet. Usually, she refuses to do so without explanation. Occasionally she claims she is afraid to sit on the toilet. The main causes of toilet phobia are passing painful bowel movements, receiving a painful enema or suppository, or being punished while on the toilet. The child rarely fears the toilet itself but rather what might happen again in the bathroom. Children who have not had any painful past experiences on the toilet usually have a severe form of toilet training resistance in which they have taken an irrevocable stand about using the toilet. Until this barrier is overcome, toilet training cannot proceed.

The parent needs to reestablish a pleasant feeling in the child about the toilet or potty chair. Specific interventions for toilet phobias begin with using stool softeners to make bowel movements soft and pain free. Then the child can be reassured that bowel movements will "feel good" when they come out. The parent can desensitize the child to the toilet in the following six steps, giving a sweet or other small treat when the child passes each milestone:

child empties diaper contents into toilet

child passes a bowel movement into diaper while in bathroom

child passes a bowel movement into diaper while sitting on toilet with lid down

child does the same with lid up

child passes a bowel movement through a "magic diaper" (a diaper with a hole cut in it) into the toilet

child passes bowel movements into the toilet without the "magic diaper."

For more about the "magic diaper" technique, see the discussion by Blum. The method also can be used for urine. Its success probably owes more to providing a face saving exit from a bad habit than desensitizing the child to a fear.

When to refer

If the child has significant emotional problems such as anger or depression, either as a primary condition or secondary to the encopresis, counseling by a psychiatrist or psychologist is indicated. A young child who is engaged in a power struggle with his parents in many areas also requires referral.

REFERENCES

1. Taubman B: Toilet training and toileting refusal for stool only: A prospective study. Pediatrics 1997;99:54

2. Wolraich ML (ed): Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Elk Grove Village, III., American Academy of Pediatrics, 1996

3. Robson WLM: Diurnal enuresis. Pediatr Rev 1997; 18:407

4. Felt B, Wise CG, Olson A, et al: Guideline for the management of pediatric idiopathic constipation and soiling. Arch PediatrAdolesc Med 1999;153:380

5. Schmitt BD: Toilet training refusal: Avoid the battle and win the war. Contemporary Pediatrics 1987;4(12):32 6. Luxem MC, Christophersen ER, Purvis PC: Behavioralmedical treatment of pediatric toileting refusal. d Dev Behav Pediatr 1997;18:34

7. Blum NJ, Taubman B, Osborne ML: Behavioral char

GUIDE FOR PARENTS

Toilet training resistance:

Daytime wetting and soiling

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 the parent brings up the subject and marches them into the bathroom. Any child who is older than 3 years, healthy, and not toilet trained after several months of trying can be assumed to be resistant to the process rather than under trained. Consider how capable your child is at delaying a bowel movement (BM) until she (or he) is off the toilet and has had a chance to hide. More practice runs (as you used in toilet training) will not help. Instead, your child now needs full responsibility and some incentives to respark her 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. Others have been spanked or punished in other ways for not cooperating. Many parents make these mistakes, especially if they have a strong-willed child.

Most children younger than S or 6 years who have daytime wetting or soiling (encopresis) without any other symptoms are simply engaged in a power struggle with their parents. They can be helped with the following suggestions. (If your child holds back BMs and becomes constipated, medicines will also be needed. Ask your doctor for the Guide for Parents on stool holding.)

Transfer all responsibility to your child. Your child will decide to use the toilet only after she realizes that she has nothing left to resist. Have one last talk with her about the subject. Tell her that her body makes pee and poop every day and that it belongs to her. Explain that her pee and poop wants to go in the toilet, and her job is to help the pee and poop come out of her body. Tell your child you're sorry you forced her to sit on the toilet or reminded her so much. Tell her from now on she doesn't need any help. Then stop all talk about this subject ("potty talk"). Pretend you're not worried about it. When your child stops receiving attention for nonperformance (not using the toilet), she will eventually decide to perform for attention.

Stop all reminders about using the toilet. Let your child decide when she needs to go to the bathroom. Don't remind her to go to the bathroom nor ask if she needs to go. She knows what it feels like when she has to pee or poop and where the bathroom is. Reminders are a form of pressure, and pressure keeps the power struggle going. Stop all practice runs and never make her sit on the toilet against her will because these tactics always increase resistance. Don't accompany your child into the bathroom or stand with her by the potty chair unless she asks you to. She needs to gain the feeling of success that comes from doing it her way.

Give incentives for using the toilet. Your main job is to find the right incentive. Special incentives, such as favorite sweets or video time, can be invaluable. When encouraging your child to use the toilet for BMs, initially err on the side of giving too much (several food treats each time). You can increase the potency of incentives by reducing your child's access to them except when she uses the toilet. If you want a breakthrough, make your child an offer she can't refuse, such as going somewhere special. In addition, give positive feedback, such as praise and hugs every time your child uses the toilet. On successful days, consider taking 20 extra minutes to play a special game with your child or take her to her favorite playground.

Give stars for using the toilet. Get a calendar for your child and post it in a visible location. Have her place a star on it every time she uses the toilet. Keep this record of progress until your child has gone one month without any accidents.

Make the potty chair convenient. Be sure to keep the potty chair in the room your child usually plays in. This gives her a convenient visual reminder about her options whenever she feels the need to pass urine or stool. For wetting, the presence of the chair and the promise of treats will usually bring about a change in behavior. Don't remind your child to use the potty chair even when she's squirming and dancing to hold back the urine.

Replace diapers or pullups with underwear. Help your child pick out underwear with favorite cartoon or video characters on it. Then remind her that the characters "don't like poop or pee on them." This usually precipitates the correct decision on the part of the child. Persist with this plan even if your child wets the underwear. If your child holds back BMs, allow her access to diapers or pull-ups for BMs only. Preventing stool holding is very important.

Remind your child to change her clothes if she wets or soils herself. As soon as you notice that your child has wet or soiled pants, tell her to clean herself up. Your main role in this program is to enforce the rule: "people can't walk around with messy pants." If your child is wet, she can probably change into dry clothes by herself. If she is soiled, she will probably need your help with cleanup. If your child refuses to let you change her, ground her in her bedroom until she is ready.

Don't punish or criticize your child for accidents. Respond gently to accidents, and do not allow siblings to tease the child. Pressure will only delay successful training, and it could cause secondary emotional problems. Your child needs you to be her ally.

Request that the preschool or day care staff use the same strategy. Ask your child's teacher or day care provider to allow her to go to the bathroom any time she wants to and to take the same approach to accidents as you do. Keep an extra set of clean underwear at the school or with the day-care provider.