Toilet Training Resistance

McKenzie Pediatrics 2007

Toilet training can be defined as delayed if the child is over 3 years of age, is otherwise healthy and has otherwise normal development, and is not toilet trained after three or more months of training. A child cannot be considered as delayed if the parents have not yet started training. Usually the delay is in bowel training, but sometimes the delay involves both bowel and bladder continence.

Toilet training delays have several causes, almost all of them behavioral. If a child can postpone urinating or defecating, or hide to do it, their neurologic system is intact, and the cause is almost certainly not medical. The signs of a true medical condition causing continued urinary accidents or bowel training delay include: pain with urination, wetting during laughter, wetting while running to the toilet, constantly damp underwear, chronic diarrhea, or chronic constipation. A hallmark of children with a true medical cause for toilet training delay is that they try very hard to use the toilet (they run to the bathroom, for example).

The most common cause of delayed toilet training is toilet training resistance or refusal. Resistant children are older than 3 years and know how to use the potty, but elect to wet or soil themselves. Most of them never sit on the toilet spontaneously, and many decline to sit on the toilet when 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. Many children have also been lectured too much, and some 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 who are delayed in toilet training have a difficult, strong-willed temperament.

In the cases, more practice runs will not help. Instead, your child now needs full responsibility and some incentives to respark her motivation. Some children who have been holding back their bowel movements and who are therefore constipation may also need the assistance of stool softening medications. Help you child in the following ways:

• Transfer all responsibility to your child: Your child will decide to use the toilet only after 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 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 that 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. Pretend you’re not worried about it. When your child stops receiving attention for 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. Don’t even remind your child to use the potty even when she’s squirming or dancing to hold back the urine. 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. Ask for your child’s input: “what would help you to remember to use the toilet?” Special incentives, such as favorite sweets or stickers, can be useful. When encouraging your child to use the toilet for bowel movements, 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. Give the incentive immediately after the child releases urine or stool into the toilet. In addition, give positive feedback, such as praise and hugs, every time your child uses the toilet.
• Give stars for using the toilet: Get a calendar for your child and post it in a visible location in the bathroom. Have her place a star on it every time she uses the toilet successfully. Decide on a reward for her to receive once so many stars have been earned; for example, 5 or 10 stars earns special movie time with a parent, or time painting, or time playing with a remote-controlled car, or a trip to the playground or library. Keep the star chart going until your child has gone one month without any accidents.
• Make certain the potty chair is 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. If there is more than one level to your home, be certain each level has an easily accessible potty chair.
• Replace diapers or pull-ups with underwear: Help your child pick out favorite character underwear. Then remind her that the characters “don’t like poop or pee on them.” This usually (though by no means always) 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. Your child needs you to be her ally.
• Request that the preschool or daycare staff, and family members such as grandparents, use the same strategies: Consistency is crucial. Keep an extra set of clean underwear and clothing at your child’s pre-school or daycare, and at the home of any family member at which your child spends a significant amount of time.

For extra help and information online, consider the following sources for advice:

1. Our office website: www.mckenzie-pediatrics.com
2. The American Academy of Pediatrics: www.aap.org/healthtopics/toilettraining.cfm
3. Mayo Clinic’s Potty Training Page: www.mayoclinic.com/health/potty-training/CC00060
4. The Potty MD: www.pottymd.com
5. Potty Training Tips: www.pottytrainingtips.com
6. The American Academy of Family Practice: www.familydoctor.org/179.xml
7. Ask Dr. Sears: www.askdrsears.com/html/10/T106600.asp
8. Going Potty: www.goingpotty.net

For retail products that might help with potty training, consider the following sites:

1. Hop On! www.musicalpotty.com
2. No More Diapers www.nomorediapers.net
3. Peter Potty www.peterpotty.com
4. Potty Patty/Potty Scotty www.pottypatty.com and www.pottyscotty.com
5. Potty Training Concepts www.pottytrainingconcepts.com
6. Potty Training Stuff www.pottytrainingstuff.com
7. Potty Training Rewards www.pottytrainingrewards.com
8. The Potty Song www.pottysong.com
9. The Potty Stool www.thepottystool.com
10. Sinkems www.sinkems.com

If your child is holding back bowel movements and is not toilet trained, please contact our office for a different handout on this subject. Or, if you have followed all of the above advice for a period of at least three months and no gains have been made in toilet training, please contact our office.