One of the most frequent and it seems frustrating toilet training enquiries received from parents is how to get their child to poo in the toilet, instead of demanding a nappy be put on. The child is often very cooperative with urinating and will happily wee on the toilet, and never have an accident, but when it comes to doing poo it can be quite a battle and you can probably guess who usually wins.
History: Master 3½ was referred to our clinic by his local GP after his very caring and patient, but increasingly exasperated mother did not know what else to do. She thought that perhaps there was something physically wrong with her son as to why he was perfectly capable of using the toilet to urinate but refused to use it for defecation. Instead, he insisted a nappy be put on and would then slink off to the privacy of his parents bedroom to do his business.
Whilst there was no ongoing history of constipation, or abdominal or rectal tenderness, he had been prescribed a mild laxative. This was to ensure that he did poo regularly, as there had been incidents where his parents refused to put a nappy on him to do poo, resulting in him holding on for five to seven days. This would then result in awful tummy pains, continued anxiety about using the toilet and general agitation and increased behavioural issues, which began affecting the entire family.
Interview and treatment: Upon presenting at the clinic Master 3½'s mother was very concerned and frustrated, as it had been going on for more than eight months. One of her main concerns was that he was to begin kindergarten in a few months and the kinder, like many other kinders, had quite strict policies regarding appropriate toileting behaviour.
Master 3½ was a quiet, reserved and cooperative boy who agreed to practice sitting on the toilet with his nappy on whilst being read a story and to do this after each meal. He also agreed that when he had to poo it was to be on the toilet but with a nappy on, definitely not in his parent's bedroom.
He was set up with a picture reward chart, where for each practice he received a sticker to put on the chart, and for each time he did a poo on the toilet with a nappy on he received a small reward of his choice. (He had a small basket of goodies to choose from). The plan being that gradually once he was comfortable sitting on the toilet with his nappy on to poo, over time, the nappy would be slowly cut away so that eventually there was no nappy and he was defecating in the toilet. The following week his mother was to phone in to report on his progress.
Progress: Master 3½ had had a few accidents early in the week, with some poos taking place in his parent's bedroom, one in his pants, two in bed at night with his nappy on and a poo at the beach. Although he was compliant with his practices on the toilet, nothing had eventuated yet on the toilet and both he and his mother were feeling that it wasn't going to happen and were a little despondent.
After much reassurance and encouragement, they agreed to persevere and to attend the clinic the following week for review. In one week, he had defecated on the toilet with his nappy on three times and had practiced on the toilet with no nappy on several occasions. Both were extremely pleased and Master 3½ brought along the reward he had received.
After another week of continued successes on the toilet, it was time to begin to cut away the nappy. His mother cut a hole in it, but when it came time for him to poo, he didn't want the nappy on and just did a poo in the toilet. This occurred again twice for the week, with both mum and the 3½ year old being very happy and proud. His reward for the week was to choose his favourite restaurant for the family to celebrate his success.
Follow-up: After 8 weeks Master 3½ was successfully using the toilet to defecate, having no accidents in his pants and continuing to poo regularly. He had recently removed his nappies at night, resulting in dry beds continually for the last four weeks.
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This article was kindly supplied by Dr Janet Hall, Boss of the Bladder Program, Richmond Hill Psychology, Melbourne