As a pediatric urologist, I hear a lot about “potty refusal” from frustrated parents.
“My 5-year-old refuses to poop on the toilet!!!” one mom 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.”
“Refusal” implies stubborn, willful, unreasonable behavior. 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 kids aren’t exhibiting defiance. They’re just not getting the signal! And they need treatment. No amount of cajoling or incentivizing will change this fact. A stretched rectum won’t respond to promises of M&Ms or screen time or to behavioral therapy.
When potty refusal usually happens
With many kids, potty refusal strikes around age 2, when they start toilet training ahead of their preschool’s deadline. Parents seek to get a jump on training, lest the child lose their spot in school.
I totally get it, given how rigidly preschools enforce their potty policies. Problem is, most 2-year-olds are too immature to toilet train. Sure, toddlers and even babies can be taught to pee and poop 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 2 hours or 2 days later.
Many kids who train early develop the holding habit. Gradually, poop piles up in the rectum, an organ not designed for storage. The stool mass dries out and hardens, so pooping hurts. A lot. So, kids further delay pooping, 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 poop.
But what adults perceive is a lack of cooperation: “refusal.”
In some kids, 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.
Chronic constipation could be the root cause of why a toddler refuses to potty train
My research has found that children potty trained before age 2 have triple the risk of developing chronic constipation and daytime pee accidents than children trained between 2 and 3. This doesn’t mean 2 1/2-year-olds are in the clear, but the odds are especially high for kids under 2.
Chronic constipation not only leads to enuresis (daytime pee accidents and bedwetting) but also encopresis (poop accidents). In some kids, the rectum becomes so floppy that stool just drops out of the desensitized rectum, without the child noticing. If preschools eliminated potty-training deadlines, many cases of “potty refusal” could be avoided. But early toilet training is just one cause of chronic constipation. Kids become constipated for many reasons—genetics, modern toilets (which take us out of the natural squat position), fear of pooping outside the home—and these children get called “refusers,” too.
How is chronic constipation treated?
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 poop. A combination of laxatives (to soften poop) and enemas (to clean out the rectum) is typically needed. The regimen I recommend, the Modified O’Regan Protocol, aka M.O.P., is spelled out in the M.O.P. Anthology.
But most kids don’t get the treatment they need because they’ve been labeled “strong-willed” or “refusers.” Schools typically refer these kids for behavioral counseling or advise parents to “say nothing,” on the theory that kids will start cooperating if they aren’t badgered.
But kids with “toileting refusal” don’t need help cooperating; they need help pooping!
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 3. But the parents were told, “This too shall pass.”
Several studies connect potty “refusal” with constipation. By and large, these studies were conducted by psychiatrists and behavioral specialists, not by GI doctors or urologists, and important conclusions were overlooked.
For example, in a study that tracked nearly 400 children, over 24% developed “stool toileting refusal (STR).” Among this group, 93% of the kids showed signs of constipation—such as hard bowel movements and painful pooping—before the onset of STR. (Italics are mine.)
In other words, these kids started toilet training with a condition that makes toilet training impossible! Yet they were labeled “refusers.”
Let’s retire the term “potty refusal,” recognize the underlying constipation, and get these kids the treatment they need.
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