Toilet Training Resistance: Encopresis without Constipation

What is encopresis?

A child with encopresis passes part or all of his normal stools into his underwear or diaper rather than the toilet.

What is the cause?

The most common cause of long-standing soiling is resistance to toilet training (bowel training resistance). Many of these children also refuse to sit on the toilet or will use the toilet only if their parent brings up the subject and marches them into the bathroom. Any child who is over 3 years old, healthy, and not using the toilet after several months of encouragement to use it can be assumed to be resisting using the toilet. About 5% of children refuse to be bowel trained.

The most common cause of resistance to toilet training is that a child is strong-willed and 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 punished for not cooperating. Many parents make these mistakes, especially if they have a child with a difficult temperament. Most children less than 5 or 6 years old with encopresis are simply engaged with you in a power struggle. More practice, such as you have used in toilet training, will not help. Instead, your child now needs full responsibility and some incentives to spark his motivation.

When encopresis begins suddenly in a toilet trained child, the cause is usually a new stress in the child's life. The stress may be a physical illness such as severe diarrhea or an emotional upset such as going to a new school. These children usually regain control of their bowels when the stress is reduced or removed.

How can I help my child overcome encopresis?

Children who have chronic encopresis can be helped with the following suggestions. If your child starts holding back stools and becomes constipated, medicines will also be needed.

1. Transfer all responsibility to your child for using the toilet. Your child will decide to use the toilet only after he realizes that you are no longer playing the “power struggle game” with him. Have one last talk with him about the subject. Tell your child that his body makes "poop" every day and it belongs to him. Explain that his "poop" wants to go in the toilet and his job is to help the "poop" get out. To help him function independently, put him in loose-fitting underwear or training pants (not diapers or pull-ups). Tell your child you're sorry you punished him for not using the toilet, forced him to sit on the toilet, or reminded him so much. Tell him from now on he doesn't need any help from you or other people.
2. Stop all talk about this subject. Stop all talk about how he’s doing with potty training (“potty talk”) when he can hear you. Pretend you're not worried about this subject. When your child stops receiving pep talks for not using the toilet, he will eventually decide to use it to gain some attention.
3. Stop all reminders about using the toilet. Let your child decide when he needs to go to the bathroom. Don't remind him to go to the bathroom or ask if he needs to go. Your child knows what it feels like when he has to "poop" and where the bathroom is. Reminders are a form of pressure, and keep the power struggle going. Stop all practice runs and never make him sit on the toilet against his will because this always greatly increases resistance to the whole process. Don't accompany your child into the bathroom or stand with him by the potty chair unless he asks you to. He needs to gain the feeling of success that comes from doing it on his own and then finding you to tell you what he did.
4. Give incentives for using the toilet. Your main job is to find the right incentive. Special incentives, such as favorite sweets or video time, can be invaluable. For using the toilet for stools, initially err on the side of giving her too much (for example, an hour of video games each time). Remember that incentives work even better if it is a special treat that your child doesn't get everyday. If you want a breakthrough, make your child an offer she can't refuse (such as going somewhere special). In addition, give positive feedback, such as praise and hugs every time your child uses the toilet for poops. On successful days consider taking 20 extra minutes to play a special game with your child or take her to her favorite playground.
5. Give stars for using the toilet. Get a calendar for your child and hang it where he sees it all the time. Place a star on it every time he uses the toilet for poops. Keep this record of progress until your child has gone 1 month without any accidents.
6. 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. Your child may need a pleasant reminder once a day, but only if he is clearly holding back. You can say "The poop is trying to get out and go in the toilet. The poop needs your help." Ask him to play the "see if you can poop before the timer goes off" game and set the timer for 5 minutes. Then let your child decide how he wishes to respond to the pressure in his rectum. Some children temporarily may need smaller treats for simply sitting on the toilet and trying.
7. Use diapers and pull-ups as little as possible. If your child refuses to sit on the toilet, passing stools in diapers is better than holding them back. (stool holding). However, don't let your child wear diapers all day. Keep your child in loose-fitting underwear or training pants, so that he has to decide each time he has an urge to pass a stool whether to use the toilet or to come to you for a diaper. Another option is to provide access to a stack of pullups in the bathroom.
8. Help your child change his clothes if he soils himself. Don't ignore soiling. As soon as you notice that your child has messy pants, clean him up immediately. The main role you have in this new program is to enforce the rule "we can't walk around with messy pants." Make changing pants a neutral, quick interaction without any show of anger. If your child is soiled, he will need your help with cleanup until at least age 6. If your child refuses to let you change him, ground him in his bedroom until he is ready.
9. Ask the preschool or day care staff to use the same strategy you are using. Ask your child's teacher or day care provider to let your child 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. Ask them to read this discussion of soiling. Be sure your baby sitter knows how to handle the situation positively and will not punish your child for soiling his pants.

When should I call my child's healthcare provider?

Call during office hours if:

• Your child holds back his stools or becomes constipated.
• Your child is afraid to sit on the toilet or potty chair.
• The resistance is not improved after 1 month of following these suggestions.
• The resistance has not stopped completely after 3 months.