Wednesday 22 October 2014

Our girl (4) refuses to use the toilet. Can you help?

Published 16/06/2014 | 02:30

Toilet training. (Picture posed)

OUR daughter has just turned four and is really struggling with doing her poo in the toilet.

This problem started nearly a year ago when she either experienced a painful poo or had a period of constipation which, since then, has really made her averse to using the toilet. While she has no problem using the toilet to do her wee, she absolutely refuses to poo there. Instead she will hide in a corner and soil her underpants, sometimes up to four times a day.

There are also occasions where she holds the poo for days. We have tried numerous interventions with her, including stickers and reward charts, looking at DVDs on toilet training and reading children's books on poo. Nothing seems to work.

While we have tried to be patient and positive with her, there are times when the whole situation becomes very frustrating. We are also concerned because she is due to start playschool in September. Recently, I took her to a paediatrician to have her checked out physically and nothing was found.

At this stage, I wonder is it a behavioural issue or a cycle she is stuck in? I would welcome any advice on how to deal with this problem.

David Coleman replies: IT IS very common for children to develop fears of using the toilet, or an aversion to using the toilet, after they have had a very painful period of constipation or a large or very solid poo that was very sore to pass.

The physical discomfort or pain becomes associated with the toilet rather than with the physiology of their bodies. In their mind, the association is made that sitting on the toilet to poo was the cause of the pain and so, naturally, they avoid sitting on the toilet to poo.

Sometimes, a behavioural reward system, where there are good outcomes for sitting to poo, can help to replace the negative associations. Sometimes, though, the negative association is so strong that it isn't easily replaced.

Unfortunately, once children stop pooing regularly, this can set up its own problems. For example, withholding poo to avoid using the toilet can lead to further constipation and this naturally, can lead to more discomfort and pain, further reinforcing the child's belief that pooing is to be avoided at all cost.

I know you say that you have tried stickers and reward charts, with no long-term success. However, I wonder how you used them?

Given the behavioural nature of how this problem seemed to start, I could imagine that a behavioural approach to resolving it could also be really effective.

Reward systems are based on the principle that if we do something, and then something good happens (a positive reinforcement), we will associate our behaviour with the good outcome and repeat the behaviour. It is a sound principle!

The key thing, however, is that the positive reinforcement needs to be something attractive to the individual and needs to occur immediately after the desired behaviour is witnessed.

Young children, especially, need immediate gratification.

So, sometimes, a behavioural reward system that encourages children to earn points, or stars, towards a later treat, just isn't motivating enough.

The other thing to consider is, what behaviour are you trying to reinforce? If it is only a successful poo in the toilet, for example, then you may never even get to use your reward if your child never manages to poo there.

So the most effective system for your daughter is probably one where you get her to sit on the toilet, with the intention to poo, about four times a day.

She gets a small reward every time she sits there (whether she poos or not). That small reward needs to be something she likes and wants, like maybe a single small chocolate button.

Then, if she poos while on the toilet, you give her a bigger reward (and also one that she can get immediately). You need to decide, with her, what those rewards will be. You also need to be really consistent and be ready to reinforce the behaviours you are looking for.

I am sure the paediatrician recommended a good diet to keep her poo soft and easy to pass, including lots of water, fruits and dietary fibre. Soiling accidents remain "accidents" and need to be matter-of-factly cleaned up, without punishment or giving out. You want it to be really clear that pooing in the toilet is the behaviour that is most desired, and so little heed needs to be paid to other behaviours like the soiling.

Reward systems like this are designed to be used in the short term (two to four weeks) on the assumption that in this time period the new behaviour will be learned and the new habit formed. While this problem may seem all-consuming now, it will resolve in time, so dig deep for your reserves of patience and calmness.

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