Refusing to use Toilet
My 3 year old son has been withholding stool for the past 6 months or so. He's seen his pediatrician about this and has been taking Miralax for the problem. He no longer has the hard, large stools that we were dealing with. Now we have another issue... He just doesn't want to sit on the toilet at all. Due to this, he has 3-4 bowel movements a day in his pants. It seems he allows himself to go a little at a time, but won't take the time necessary to sit on the toilet and finish. Washing out underwear is getting tiresome and it is difficult to even leave the house anymore without lots of wipes and changes of clothes.What can I do?
Dear “Frustrated Mom”,
Thank goodness that your son is not holding in his stools anymore, because that could be a major problem. Even though it is not pleasant to see him have bowel movements in his pants, be encouraged that he is headed in the right direction.
I have had a lot of success using Miralax for constipation, Encopresis and Stool Withholding. Miralax loosens the stools and as a result having a bowel movement no longer is difficult or painful for a child. This puts a child in a better position to become potty trained.
In some cases the Miralax loosens the stools so much that it is difficult for the child to control them. If the stools are runny or too soft, the child may not be able to get to the bathroom on time or the stools may slip out and the child can have frequent accidents in their pants. If this is the case your son may just need a slight adjustment in his medication dosage. By giving him a little less Miralax, the stools should become a little firmer and your child may have better control. Your doctor can guide you regarding medication adjustments if they are necessary in your son’s case.
If your son’s stools are normal consistency, coming out in soft logs, and he still goes in his pants then this is a different situation. Encopresis or Stool Withholding tends to weaken a child’s bowel musculature. It also alters the child’s sensory feedback or awareness of need to defecate.(1) The first step in gaining normal bowel control is having normal formed bowel movements on a regular basis and not holding them in. The next is to learn to sense the need to go and strengthen their abdominal musculature. This process can take some time and a child may not be able to control his bowels until this is accomplished.
If your son knows when he is going to have a bowel movement and chooses to go in his pants instead of the toilet this may be due to a fear of the toilet bowl. Children with Encopresis and Stool Withholding have bad memories of going on the toilet because of painful bowel movements. Because of this they frequently develop a fear of having a bowel movement or a fear of the toilet. (2) If your son is refusing to use the toilet because he associates it with pain.
In order to turn potty time into a more pleasant experience, you may need to let your son a potty instead of the toilet for a little while. It is a good idea to make the potty a special place. To do this you can bring him to the store with you and have him pick out a potty just for him.(3) This way he can feel that he has some control over the situation and he will feel that it is his choice to use the potty. Let him decorate his potty with stickers of his favorite hero; superman, batman or whichever way he wishes. This way he can take ownership of his potty and ultimately want to use it.
Once your son has his own place to go, then reinforce the need for scheduled potty time. Let him know that he is expected to sit on the potty for 5 minutes, twice per day. (2) Pick times that he is more likely to have a bowel movement such as right after a meal or after a bath. Even if he doesn’t have a bowel movement, praise him for sitting.
Some children refuse to use the toilet becasue it is a power struggle between mother and child. A way to combat this is to let him spend time with older children. Many times children are more willing to listen and learn from their peers rather than listen to their parents. Have your son spend time with older cousins, neighborhood children or friends. Let him observe how “big kids” use the bathroom. There is no need to verbally tell him this, he will notice on his own if he spends time with them. Most kids want to be like their older “friends” and will make an effort to change just to be like the “big kids”.
When your son has an accident, it is best to have a matter of fact attitude when cleaning the mess. The less attention he gets from having accidents, the better the chance he won’t use his accidents as a way to get your attention. In addition, it is a good idea to concentrate on praising your son for having a bowel movement and not holding it in, rather than concentrating on the fact that he won’t go in toilet.
Once your son consistently uses the potty for a period of time, and has not had a painful stool for 6 months, you can consider transferring him to the toilet. Purchasing and decorating special stool that he can rest his foot on while having a bowel movement may be the incentive that he needs at that point.
In the meantime, be assured that it is normal to become frustrated and feel like your child will never learn. Don’t lose hope because potty training in general takes a lot of patience and time. In addition, it can take 6 months for a child with a history of stool withholding to lose the fear of toileting. (2) If the situation is going on longer than this you should talk to your Pediatrician about it because in some difficult cases, family therapy may be warranted. (2)
If you are interested in reading other Pediatric Advice stories about this subject:
(1)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:61.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1044.
(3)Rosenthal M. Suggestions to help parents change their toddler’s behavior outlined. Infectious Diseases in Children. 2006.March:44.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice Website