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potty training refusal

Toilet training done badly can lead to medical complications, including dysfunctional voiding, constipation and impaction-and even child abuse. This article describes in detail how to treat toilet training problems before they cause harm.
Toilet training can be defined as delayed if the child is over 3 years of age, has normal development, and is not toilet trained after three or more months of training. (This definition excludes families who have not yet started toilet training.) Usually the delay is in bowel training. Taubman found that 22% of bladder-trained children were not bowel trained one month after completing bladder training.' [For information on toilet training basics, see "Toilet training: Getting it right the first time," in the March issue, accessible at ] Although the Diagnostic and Statistical Manual for Primary Care Child and Adolescent Version uses 4 years of age as a cutoff for abnormal toilet training delays, it makes sense to evaluate delays at 3 years of age to prevent ongoing harmful approaches by parents. If the parents are mishandling toilet training problems, it's a mistake to allow them to continue to do so for an additional year before intervening. If, for example, parents are punishing the child for noncompliance or forcibly holding the child on the toilet, these negative interactions will be much harder to undo and repair with time. Calling delays abnormal can wait until 4 years of age, but evaluation and intervention should begin sooner. Differential diagnosis of toilet training delays Toilet training delays have several causes, both behavioral and organic. The cause is most often behavioral. Organic causes are rare. Questions about neurologic causes arise often, but if the child can postpone urinating or defecating or hide to do it, neurologic input is clearly intact. The most common organic cause of isolated daytime wetting is a urinary tract infection. Other causes to consider are bubble bath urethritis, giggle incontinence, urgency incontinence, or an ectopic ureter. Indications for pursuing these diagnoses are, respectively: dysuria, wetting during laughter, wetting while running to the toilet, or constantly damp underwear. Children with diarrhea or constipation during toilet training also need a medical evaluation. A hallmark of children with an organic cause for delayed toilet training is that they try very hard to use the toilet (they run to the bathroom, for example). Children with delayed toilet training require a careful workup to help individualize the treatment plan. In general, the workup is mainly historical and the physical examination is not very beneficial except for detecting unreported constipation. One of the most important facts to determine is whether or not the child will sit on the toilet. If he will, does he do it spontaneously, only with reminders, when restrained by the parent, or with threat of punishment? If the parent uses physical punishment, examine the child for evidence of physical abuse. Toilet training resistance The most common cause of delayed toilet training is resistance or refusal. This entity was first described in depth in 1987 and elaborated in several subsequent articles. Resistant children are older than 3 years and know how to use the potty but elect to wet or soil themselves. They have nonretentive encopresis and diurnal enuresis. Most of them never sit on the toilet spontaneously, and many decline to sit on the toilet when the parents prompt them to do so. Most children who are resistant to toilet training are enmeshed in a power struggle with their parents. The cause of the power struggle is usually reminder resistance-an oppositional response to excessive reminders to sit on the toilet. In addition, most resistant children have been held on the toilet against their will. The child's contribution to the power struggle is usually a difficult, strong-willed temperament. Treating toilet training resistance The "Guide for Parents: Toilet training resistance," at the end provides detailed instructions on how to get a resistant child back on track. Steps that the physician can take in the office to motivate a resistant child include the following: Transfer all responsibility to the child. Tell the child that it is her body, and "the pee and poop belong to you." Tell her that she doesn't need anybody to help her anymore, that it's up to her. Ask the parents to stop all reminders to use the potty. Reminders and practice runs are what keep the power struggle going. Children older than 3 years never need reminders to help them become toilet trained. Make the child think that using the toilet is her idea. Brainstorm incentives. Once the power struggle has been dismantled, parents need to come up with the right incentive to achieve a breakthrough. Many parents have a defeatist attitude about incentives and think they have exhausted their options. They say things like "She has so many toys that she won't work for anything new" or "She doesn't care if we take things away." Four rules make incentives powerful: The incentive is something that the child strongly desires. Ask for the child's input: "What would help you remember to look after your poops?" It is given immediately after the child releases urine or stool into the toilet. The child is given access to the incentive for 30 to 60 minutes.

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