Difficult Toilet Training

Alison Schonwald MD

Although most children in the U.S. are toilet trained by three to four years of age, a group of developmentally on-target children have trouble meeting this milestone. It is hard to know how large this group of difficult toilet trainers is, since many families are embarrassed to share their struggle with family, friends and primary care providers. However, one recent study followed 380 children from age 17-19 months and found that 24% of them refused to use the toilet as some point.

A child is ready to toilet train when he can feel and communicate the need to go, hold it in until arriving at the potty or toilet, remove his clothes, and sit long enough to stool or urinate. Parents recognize a child's readiness when the child stays dry for a few hours between urinating, lets a parent know when he has a dirty diaper, and is interested in imitating grown up activities such as wearing underwear or sitting on the toilet.

But why do some children, who succeed in so many other areas of their lives, have so much trouble with toilet training? Two associated factors have recently been identified.

Constipation
In our study at Children's Hospital in Boston, 78% of 46 children with difficult toilet training were constipated. Constipated children have painful stools, large stools, and need to push hard. Other studies have shown that constipation comes before toilet refusal; presumably, since it hurts, the child is more reluctant to go on the toilet.

Temperament
Temperament is a person's behavioral style, the innate tendencies that determine how we interact with, and respond to our environment. About 10% of people have difficult temperaments, 40% are easy, 15% are slow to warm up, and the remaining 35% are intermediate. Several temperament traits cluster into these four temperament classes.

Our study found a difference in difficult temperament traits when 46 difficult toilet trainers were compared to 62 preschoolers who trained easily. Difficult toilet trainers were more likely to be "less adaptable," meaning that, even with multiple exposures, they have more trouble adjusting to new situations. They were more negative, demonstrating more crying and whining, and were less persistent, becoming frustrated and giving up more easily. When difficult toilet trainers were compared to children who toilet train easily, they were more likely to withdraw from a new situation rather than readily accept it.

Because of temperament, difficult toilet trainers rarely have easy behavioral styles. In our study, 42% of children who toilet trained easily had easy temperaments, but only 2% of difficult toilet trainers had easy temperaments. In this study, if you had an easy temperament, you were 33 times more likely to be easily toilet trained!

Parenting Style
By the time difficult toilet training comes to the attention of the child's doctor, the child and parent are usually engaged in a battle of the wills. The parent is often begging, yelling, bribing, crying, and frantic for the child to toilet train. Our study found no difference in the parenting style of those whose children toilet train easily and those whose children did not.

What Does This Mean?
First of all, we can use this information to understand why children refuse to toilet train. It probably hurts to go, or has hurt sometime in the past due to constipation. Because of the child's temperament he may have more trouble approaching this challenge, persevering, and may be more apt to become negative and frustrated. Despite the efforts of parents, a child's poorly adaptable temperament may prevent toileting from getting any easier. Also, a child's bowel status and temperament must be considered when helping him toilet train.

What Should You Do?
Talk to your primary care provider about constipation. A constipated child can be treated with diet or medication, depending on the extent and duration of his constipation. You cannot expect a child to go if it hurts to go!

Break the task of toilet training into manageable parts. Rather than expecting the child to poop in the toilet, start by merely having him sit on the toilet, stool in the bathroom (not on the potty), wipe, or flush. Make it a positive experience by rewarding the child with small treats for succeeding, such as stickers, a special activity with the parent, or a star on a chart. Remove added stress the child may feel. Eliminate discussion about toileting other than at the time of the child's toileting tasks.

Every week, offer the child the opportunity to work on a new task. Rewards should continue and pressures should be avoided. Continue to monitor the child's bowel status, ensuring that stools are soft and controllable, and easy to pass.

If all else fails, take a break from toileting for a month or two. Be sure to avoid conversation about the issue and to eliminate any pressure the child may feel. Use that time to improve the child's stooling regularity with diet changes or medication suggested by your child's doctor. Later, introduce a task the child is sure to be able to do (such as flushing) so that he feels confident with success. Slowly add more toilet training jobs, such as wiping or sitting. In some instances, help from a developmental pediatrician or behavioral psychologist may also be necessary.

Alison Schonwald, M.D., is a Developmental Behavioral Pediatrician at Children's Hospital, Boston. She is the medical director of a school problems clinic, with expertise in toilet training, attention and learning problems, and psychopharmacology for children with developmental disabilities.
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