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Potty Training: Take 2

There are many reasons why a child refuses to potty train.  Tops amongst them are chronic constipation (producing hard, painful BMs) and resistance to feeling controlled.
The Stool Withholder
Some children decide to withhold bowel movements during potty training, causing constipation, painful stools and even impaction (where a solid stool is stuck in the rectum, but diarrheal stool leaks around it causing a constant, uncontrollable ooze.)  When this impaction lasts for too long, the rectum and colon become stretched out of shape and lose tone.  Stool builds up and the child loses control over stooling, or refuses to stool due to the painful nature of passing large, hard stools.
The first step in treating stool withholding (or encopresis) is to allow the child to stool in a diaper without reprimand.  You may need to start stool softeners such as Miralax to ease passage of the stool until the rectum regains tone and control (see our article on CONSTIPATION for further instruction.) This can take several weeks to months.
Explain to the child why they need to poop every day.  “Your body makes a poop everyday, and it wants to come out. “  Creativity helps- talk about the poop party that all poops like to go to in the sewer- celebrate when they produce a poop (in the diaper or toilet) that can then be flushed down to the party!
The Resister (and a continuation for the withholder)
The next step is to transfer all responsibility for peeing and pooping onto the child.  This takes the power struggle between parent and child over using the toilet away.  Allow him to pee/poop in a diaper (or ask for a diaper to poop in.)  Don’t remind him to pee or poop (unless you see him trying to withhold stool, and gently remind him of the poop party his poop wants to go to.)  If you use enough miralax daily, stools will eventually become too soft to withhold.
If your child has trained successfully for pee, allow them to wear underwear as a reward, and ask for a diaper to poop in.
Start an incentive program to celebrate a successful pee/poop in the potty.  Introduce a reward chart or jar filled with small toys.  Alternatively, offer a special experience (such as using an iPad for 10 minutes, a special dress up costume, video time, fun experience such as a trip to the ice cream store) for a successful poop.  For an incentive to be effective look to fulfill these 4 conditions:
  1. Your child strongly desires the incentive (ask for their input- “what would help you remember to go poop in the potty?”)
  2. You give the incentive immediately after the child meets the goal. (pees or poops in the potty.)
  3. The goal has to be attainable (if your rule is staying dry all day to earn an incentive, and your child has yet to even pee in the potty, they will give up before ever getting a taste of the reward.)
  4. You, not the child, control the incentive (allow a limited time of access to the privilege, and do not allow its use at any other time.)
Never withhold social reinforcers such as physical attention (hugs) or parent-child activities (reading, playing) as they are essential to your child’s growth and sense of mental well-being.
If your child pees/poops in the diaper, change it in a neutral, quick manner.  Try not to use negative pressure (acting upset, dismayed, angry with the child.)  Simply remind the child that “people don’t walk around in dirty diapers.” If the child refuses to change or be changed, do not allow them to play or participate in any activity until they agree to clean up.  Flush any stool down the toilet to join the poop party.
At the same time, keep a potty close when possible along with a visual reminder of the incentive.  Avoid frequent verbal reminders, as this will often prompt a “refuser” to further resist training.  Pretend that you really don’t care if they pee/poop in their diaper till they are 20 (I promise they won’t!)  Reminders are a form of pressure, and pressure with keep the power struggle going.
If your child is in daycare or preschool, talk with the care providers about continuing the same methods of training within the classroom.
If your child continues to appear very distressed by or resistant to training, consider putting all efforts on hold for a month or two to allow you both to de-stress.