Children who refuse to be toilet trained either wet themselves, soil themselves, or try to hold back their bowl movements (thus becoming constipated). Many of these children also refuse to sit on the toilet or will use the toilet only if the parent brings up the subject and marches them into the bathroom. Any child who is over 2 1/2 years old, healthy, and not toilet trained after several months of trying can be assumed to be resistant to the process, rather than untrained. Consider how capable your child is at delaying a bowel movement until she is off the toilet. More practice runs (as you used in toilet training) will not help. Instead your child now needs full responsibility and some incentives to re-spark her motivation.

The most common cause of resistance to toilet training is that a child has been reminded or lectured too much. Some children have been forced to sit on the toilet against their will, occasionally for long periods of time. A few have been spanked or punished in other ways for not cooperating. Many parents make these mistakes, especially if they have a strong-willed child.

Most children younger than 5 or 6 years of age with soiling (encopresis) or daytime wetting (without any other symptoms) are simply engaged with you in a power struggle. These children can be helped with the following suggestions. If your child holds back bowel movements and becomes constipated, medicines will also be needed.

Helping your child with daytime wetting or soiling:

1. Transfer all responsibility to your child. Your child will decide to use the toilet only after he realizes that he has nothing left to resist. Have one last talk with him about the subject. Tell your child that his body makes "pee" and "poop" every day and it belongs to him. Explain that his "poop" and "pee" wants to go in the toilet and his job is to help the "poop" or "pee" get out. Tell your child you're sorry you punished him, forced him to it on the toilet, or reminded him so much. Tell him from now on he doesn't need any help. Then stop all talk about this subject. When your child stops receiving conversation for nonperformance (not going), he will eventually decide to perform for attention.
2. Stop all reminders about using the toilet. Let your child decide when he needs to go to the bathroom. He should not be reminded to go to the bathroom nor asked if he needs to go. He knows what if feels like when he has to "poop" or "pee" and where the bathroom is. Reminders are a form of pressure, and pressure doesn't work. He should not be made to sit on the toilet against his will because this will foster a negative attitude about the whole process. Don't accompany your child into the bathroom or stand with him by the potty chair. He needs to get the feeling of success that comes from doing it on his own and then finding you to tell you what he did.
3. Give incentives for using the toilet. If your child stays clean and dry, he needs plenty of positive feedback, such as praise, smiles and hugs. This positive response should occur every time your child uses the toilet. If a child soils or wets himself on some days and not others, this recognition should occur whenever he is clean for a complete day. On successful days consider taking 20 extra minutes to play a special game with your child or take him for a walk to the playground. Sometimes special incentives, such as favorite toys or video time, can be invaluable. For using the toilet, err on the side of giving him too much. If you want a breakthrough, make your child an offer he can't refuse.
4. Give stars for using the toilet. Get a calender for your child and post it in a conspicuous location. Place a star on it every time he uses the toilet. Keep this record of progress until your child has gone 2 weeks without any accidents.
5. If your child has never sat on the toilet, try to change his attitude. First, give him choices by asking if he wants to use the big toilet or the potty chair. If he chooses the potty chair, be sure to keep it in the room he usually plays in. For wetting, the presence of the chair and the promise of reward will usually bring about a change in behavior. A few children may need rewards for simply sitting on the toilet and trying. However, don't accompany your child into the bathroom or stand with him by the potty chair. He needs to do it on his own.
6. Remind your child to change his clothes if he wets or soils himself. As soon as you notice that your child has wet or messy pants, ask him to clean himself up immediately. The main role you have in this program is to enforce this rule. If your child is wet, he can probably change into dry clothes by himself. If your child is soiled, he will probably need your help with cleanup but keep him involved. Have him rinse the soiled underwear in the toilet. He may think this is "yucky" and be motivated to keep his pants clean.
7. Don't punish or criticize your child for accidents. Respond gently to accidents, and do not allow siblings to tease the child. Do not put your child back into diapers unless he needs to be on laxatives. Pressure will only delay successful training, and it could cause secondary emotional problems.
8. Ask the preschool or day-care staff to use the same strategy. Ask your child's teacher or day-care provider for unlimited privileges to go to the bathroom any time your child wants to. Keep an extra set of clean underwear at the school or with the day-care provider.

Edited by Lake Area Pediatrics

Barton D. Schmitt, MD