Potty refusal

Is your child consistently reluctant to use the potty to do a poo? Such children are often labelled ‘potty refusers’ but there may be an underlying condition that’s causing them anxiety and even pain. Steve Hodges M.D* calls for a better understanding of kids who flatly refuse to use the potty.


As a pediatric urologist, I hear a lot about ‘potty refusal’ from frustrated parents. ‘My five-year-old refuses to poo on the toilet!’ one mum emailed me. Another wrote: ‘My daughter is a nightmare to potty train. She flat out refuses to go to the bathroom when she clearly needs to. Then she has an accident.’

...most two-year-olds are too immature to toilet train.

The terms toilet refusal and toileting refusal syndrome even surface in medical literature. Refusal implies stubborn, willful, unreasonable behaviour. But let me offer a more evidence-based explanation: children who resist using the toilet are either not developmentally ready for toilet training or are chronically constipated. In the second instance, the child’s rectum has become stretched by a pile-up of stool and has lost the tone and sensation needed for complete evacuation.

These children aren’t exhibiting defiance. They’re not getting the signal and for that they need treatment. No amount of cajoling will change this.

With many children, ‘potty refusal’ strikes around age two, when they start toilet training in preparation for pre-school. Parents seek to get ahead on training to make life easier all round. Preschools have different potty policies and some are more rigid than others. The problem is, most two-year-olds are too immature to toilet train.

It's true that most toddlers and even babies can be taught to pee and poo on the toilet. But don’t be fooled: That’s entirely different from possessing the judgment to heed your body’s signals in a timely manner, not two hours or two days later.

Many kids who train early develop the holding habit. Gradually, poo piles up in the rectum, an organ not designed for storage. The stool mass dries out and hardens, so going to the toilet hurts. This can lead to children further delaying moving their bowels, so more stool piles up and the rectum stretches further, compromising its tone and sensation mechanism. In other words, the child literally cannot squeeze out a complete bowel movement or even feel the urge to do so. Understandably, many parents see this as a lack of co-operation or even downright refusal.

In some children, the enlarged rectum presses against and aggravates the nearby bladder nerves. The bladder contracts and empties without warning. So, now the child appears to be refusing to pee in the potty, too!

My research has found that children trained before the age of two have triple the risk of developing chronic constipation and daytime pee accidents of children trained between two and three years. This doesn’t mean that two-and-a-half year olds are in the clear, but the odds are especially high for kids under two.

Chronic constipation not only leads to enuresis (daytime pee accidents and bedwetting) but also encopresis (poo accidents). In some kids, the rectum becomes so floppy and desensitised that stool just drops out without the child noticing.

Many cases of potty refusal could be avoided if children could take things at their own pace. But early toilet training is just one cause of chronic constipation. Kids become constipated for many reasons —genetics, life in the 21st century — and these children are often labelled refusers too.

While I advocate a laissez-faire approach to toilet training, I recommend a proactive approach to treating constipation and helping the child overcome the habit of delaying poo. A combination of laxatives (to soften poo) and enemas (to clean out the rectum) is typically needed. But most kids don’t get the treatment they need because they’ve been labelled strong-willed or refusers.

Left untreated or under-treated, chronic constipation often worsens.

In truth, kids with toilet refusal don’t generally need help cooperating; they need help to poo! Parents are often advised to chill out in these circumstances and to wait until children are ‘ready’. But I advise parents against making that assumption. Left untreated or under-treated, chronic constipation often worsens. I have a huge caseload of teenage patients with enuresis and/or encopresis. In most cases, the red flags were apparent by age three. But the parents were told: ‘This too shall pass.’

Several studies suggest that potty refusal causes constipation. By and large, these studies were conducted by psychiatrists and behavioural specialists, not by doctors or urologists, and important conclusions were overlooked. For example, in a study that tracked nearly 400 children over 24 per cent developed ‘stool toileting refusal’ known as STR. But among this group, 93 per cent of the kids showed signs of constipation — such as hard bowel movements— before the onset of STR.

In other words, these children started toilet training with a condition that makes toilet training impossible! Yet they were labeled refusers. If a child with reading difficulties tossed aside Harry Potter, the child wouldn’t be called a “reading refuser.” The child would get help.

So let’s abolish the term ‘potty refusal’, recognise the underlying constipation, and get these kids the treatment they need.

* Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and co-founder of Bedwetting and His books include Bedwetting and Accidents Aren’t Your Fault and The M.O.P. Book: The Proven Way to STOP Bedwetting and Accidents in Toddlers Through Teens.

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