Toilet training resistance and Stool Toileting Refusal

Explaining the behavior and discussing ways to handle

This page discusses toilet training resistance in the form of Stool Toileting Refusal (STR), or: toileting refusal for bowel movements.

STR is a familiar behavior among potty trainers; a study by Taubman (Ref. #1: Toilet Training and Toileting Refusal for Stool Only: A Prospective Study) reveals that 22% of the potty-trainees who participated in the study had experienced at least 1 month of stool toileting refusal.

STR behavior varies in duration. It could last days, weeks, or months. When lasted long enough it can be a cause for delayed potty training, along with a great deal of stress and frustrations.

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What duration is considered “long enough” for STR?

The answer is subjective and very much dependent upon one’s approach to toilet training; if you view toilet training as a long process, designed to last several months, (a view that normally goes with the child-oriented approach) -- then you may not consider 1 month of stool toileting refusal to be a long period.

On the other hand, if you view toilet training as a short, more focused procedure, 1 month of STR would be considered long.

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Side effects for stool toileting refusal

Stool withholding:

Taubman’s study (Ref. #1) finds strong association between stool toileting refusal and stool withholding behavior:

~12% of the study children developed stool withholding during toilet training, and 80% of these children were “toileting refusers”. Looking at this data from a different perspective would show that 46% of the stool toileting refusers had also developed a behavior of stool withholding.

Another side effect of stool toileting refusal is Delayed potty training:

If stool toileting refusal goes on for weeks and months, it delays the progress of toilet training. Lack of successful toilet training by 42 months of age can cause a great amount of stress and frustration in the family, especially if the training has been going on for months.

Moreover, it can subject the child to unpleasant situations where he’s being laughed at (by other children), or criticized.

Lastly: is constipation a side effect of stool toileting refusal?

Blum et al (Ref. #5: During toilet training, constipation occurs before stool toileting refusal) find constipation to be a contributing-factor in stool toileting refusal and not a result of it.

According to this study:

When children experience “hard bowel movements” or painful defecation along with stool toileting refusal, the first episode of constipation usually occurs before the STR, suggesting that the tendency-for-constipation was already present.

Constipation may not be the result of STR behavior, but it definitely is caused or increased as a result of stool withholding behavior, which is associated with STR many times.

Possible reasons for toilet training resistance and stool toileting refusal

What causes children to develop toilet training resistance, and specifically toileting refusal for bowel movements?

The following observations come from Studies performed around the subjects of difficult toilet training and stool toileting refusal:

• Relation to difficult temperaments and/or behavioral difficulties:
  
  Schonwald el al (Ref. #3: Factors Associated with Difficult Toilet Training) presents a trend toward children with difficult toilet training (DTT) having more difficult temperaments than rest of the children in the study -- in the sense that DTT’s were more likely to be:
  * Less adaptable
  * More “negative in mood”
  * Less persistent
  and
  * “Lower in approach”

  DTT’s were also more likely than study’s-control-children to be constipated, hide to stool, and ask for pull-ups in which to defecate.

  Blum and Taubman et al (Ref. #4: Behavioral characteristics of children with stool toileting refusal), did not see a relation between stool toileting refusal and having more behavioral problems, but found a trend toward children with STR having a more difficult temperament, and more problems with constipation and painful bowel movements.

  The conclusions from both these studies seem to completely support one another.

• Relation to family environment:
  
  Bruce Taubman (Ref. #1: Toilet Training and Toileting Refusal for Stool Only: A Prospective Study) finds Stool Toileting Refusal to be associated with the presence of younger siblings and parents’ inability to set limits for the child.

• Relation to age of toilet training:
  
  The same study (Ref. #1) also relates between “toilet refusers” and training at a later age. More specifically:
  
  
  50% of the children who trained between 42 and 48 months, and 73% of the children who trained after 48 months, had experienced stool toileting refusal.

Toilet training resistance and anxiety

Dr. David R. Fleisher (Ref. #6: Understanding Toilet Training Difficulties), explains that anxiety may interfere with toilet learning.

According to Dr. Fleisher’s article, sources for toileting anxiety could be:

* Fear of anticipated pain (if the child has already experienced painful defecation)
* Conflict with parents around toileting
* Emotional traumas

If a child has never experienced painful defecation, then he or she doesn’t feel threatened by their bowel movements.

On the other hand, if a child passes a hard-stool he might feel pain. This pain is: unexpected to the child, it occurs in a hidden part of his body, and it’s associated with a bodily function that is not felt to be entirely under his control.

This makes pooping scary, and might make a child unwilling to defecate in toilet.

[For the child, toilet represents a new way of defecating. As such, it can be perceived by him/her to be not-as-safe-as defecating in diapers.]

How to handle toilet training resistance

It’s important for the parents to identify, as much as possible, the source of their child’s toilet training resistance:

Is resistance coming from toileting anxiety of some sort (as described in previous section)?

Or -- is toilet training resistance more related to power struggles with the parents, boundaries issues, etc?

Whether it’s one or the other, parents need to provide leadership to their child. That leadership has to be “tuned” according to the nature of toilet training resistance.

If it’s a boundaries issue, effective parental leadership would probably include setting limits and setting clear expectations. Not by getting angry or aggressive, rather by being assertive and communicating a clear message to the child.

If it’s an anxiety issue, then it’s a different story.

According to Dr. Fleisher (Ref. #6: Understanding Toilet Training Difficulties), parental leadership in handling toileting anxiety would be most effective if it is sensitive to and appreciative of the child’s feelings and cognitive level.

Parents should not try to force or “dictate” toileting on their child if that child experiences toileting anxiety.

Dr. Fleisher says parents’ task in this case is to support the child’s efforts, and avoid any measures that would increase conflict and anxiety.

Example for supporting child’s efforts: Parents may apply effective stool softeners until defecation is no longer threatening to the child.

How can we tell the source of toilet training resistance?

Probably, by being mindful; by listening carefully to the “tone of resistance” and trying to pick up where it’s coming from.

There’s always the option of seeking help from a professional source (clinical, educational), if we’re not sure what to do.

One last point regarding ways to handle toilet training resistance:

There was a particular study by Bruce Taubman et al (Ref. #2: Stool Toileting Refusal: A Prospective Intervention Targeting Parental Behavior), which instructed parents in the intervention group to avoid using negative language or gestures in relation to pooping.

This came from the assumption that such behavior by parents, promotes a negative connotation for feces and defecating.

The result of this intervention was: Occurrence of stool toileting refusal was not decreased, but its duration was shortened. So it’s something to consider.

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References and Sources used in Toilet Training Resistance page

1) Bruce Taubman MD. Toilet Training and Toileting Refusal for Stool Only: A Prospective Study. Pediatrics.January 1997;Vol 99;No. 1;pp 54-58.

2) Bruce Taubman MD, Nathan J. Blum MD; Nicole Nemeth MD. Stool Toileting Refusal: A Prospective Intervention Targeting Parental Behavior; Arch Pediatr Adolesc Med. 2003;157:1193-1196.

3) Alison Schonwald MD, Lon Sherritt, MPH, Ann Stadtler CPNP, Carolyn Bridgemohan MD. Factors Associated With Difficult Toilet Training. Pediatrics.June 2004;Vol. 113;No. 6;pp 1753-1757.

4) Nathan J. Blum MD, Bruce Taubman MD, Osborne ML. Behavioral characteristics of children with stool toileting refusal. Pediatrics.Jan 1997;Vol. 99;No 1;pp. 50-3.

5) Nathan J. Blum MD, Bruce Taubman MD, Nicole Nemeth MD. During toilet training, constipation occurs before stool toileting refusal. Pediatrics.June 2004;Vol. 113;No 6.

6) David R. Fleisher, MD. Understanding Toilet Training Difficulties. Pediatrics.June 2004;Vol. 113;No. 6;pp. 1809-1810.