Definition

• A child who refuses to be toilet trained. He passes stools into his underwear or pull-up. The medical term for this is encopresis.
• This handout discusses children who have this problem but are not constipated.

Health Information

Causes

• The most common cause of chronic soiling is resistance to using the toilet. This is called bowel training resistance. Many of these children refuse to even sit on the toilet. They may sit on the toilet only if the parent requires it. But, they don’t release the stool until after they get off.
• Bowel training is usually accomplished in 2 to 3 months. Healthy children over 3 who aren’t using the toilet after 3 months have toilet training resistance. About 5% of children refuse to be bowel trained.
• The most common cause of toilet training resistance is a strong-willed child. In addition, they have been reminded or lectured too much. Most children have been forced to sit on the toilet against their will. A few have been punished for not cooperating. Many parents make these mistakes. This can be common if you have a child with a difficult temperament.
• Most children under 6 with encopresis are simply engaged in a power struggle with you. More practice, such as you used in toilet training, will not help. Instead, your child now needs to take full responsibility. He will need some incentives to spark his interest.
• Sometimes, encopresis begins all of a sudden in a toilet trained child. When this happens, the cause is usually a new stress. The stress may be a physical illness such as severe diarrhea. It can also be an emotional upset such as going to a new school. These children usually regain bowel control when the stress is reduced or gone.
• If your child starts holding back stools and becomes constipated, medicines will be needed.

Care Advice

1. Transfer All Responsibility to Your Child:
   • Your child will decide to use the toilet only after giving up the "power struggle game".
   • Have one last talk about the subject.
   • Tell your child that the body makes "poop" every day. It’s your child’s poop.
   • Explain that "poop" wants to come out. Your child’s job is to help the "poop" come out.
   • Tell your child you’re sorry you reminded him so much in the past. Also, apologize for any past punishment or forced sitting on the toilet.
   • Tell your child from now on they don’t need any help.
2. Stop All Reminders About Using the Toilet:
   • Let your child decide when they need to use the toilet. Don’t remind him to use the bathroom or ask if he needs to go.
   • They know what it feels like when they have to "poop".
   • Reminders are a form of pressure, and pressure keeps the power struggle going.
   • Stop all practice runs.
   • Never make your child sit on the toilet because this always greatly increases resistance.
   • Don’t go with your child into the bathroom unless he asks you to.
   • Your child needs to feel success when he does it his way.
3. Stop All Talk About This Subject:
   • When your child is around, stop talking about toilet training.
   • Pretend you’re not worried about this subject.
   • When your child stops receiving attention about not going, they’ll eventually decide to go.
4. Give Incentives for Using the Toilet:
   • Your main job is to find the right incentive. Incentives should replace reminders.
   • Special rewards, such as favorite sweets or video time, can be invaluable. For using the toilet for stools, initially use big rewards. For example, special games or going somewhere special can be used.
   • Remember that an incentive works even better if it is special. That means a treat that your child doesn’t otherwise get.
   • If you want a breakthrough, make your child an offer they can’t refuse.
   • For details, see the handout: Incentives for Motivating Your Child.
5. Keep a Sticker Chart for Using the Toilet:
   • Get a calendar for your child. Post it in a very obvious area. Call it the Good Pooper chart.
   • Have them place a star on it every time they poop in the toilet. You can also use stickers that your child picks out.
   • Keep this record of progress until your child has gone 1 month without any accidents.
6. Not Sitting on the Toilet - How to Help:
   • Keep the potty chair in the room he usually plays in.
   • If he is clearly trying not to go, remind him in a kind way. Say: "The poop wants to come out and go in the toilet. The poop needs your help." Try to make it funny.
   • Then, let your child decide how to respond to the pressure in their bottom.
   • You may even need to say: " You don’t know how to sit on the toilet". Your child will want to prove you wrong.
   • Some children may need smaller treats for simply sitting on the toilet.
7. Use Diapers or Pull-ups As Little as Possible:
   • Keep your child in loose-fitting underwear (or training pants) during the day. Wearing underwear also gives your child an incentive to maintain bladder control (urine).
   • If your child starts stool-holding, put him back in diapers.
   • Another option is to keep pull-ups next to the potty chair or toilet.
   • Your child can decide whether to use the toilet or put on a pull-up.
8. Help Your Child Change Clothes for Soiling:
   • Don’t ignore soiling.
   • Your main role is to enforce the rule "people can’t walk around with messy pants."
   • Your child will need your help with cleanup until at least age 6.
   • Make changing a neutral, quick interaction. Always dump the stool in the toilet with your child’s help.
   • If your child refuses to let you change them, ground your child. Put them in time-out until they are ready.
9. Ask the Preschool/Child Care Staff to use the Same Strategy as Yours:
   • Talk to your child’s teacher or child care provider.
   • Ask that your child use the bathroom any time they want to.
   • Keep extra clean underwear at school or with the child care provider.
   • Ask them to read this handout.
   • Be sure your baby sitter knows how to handle the situation positively.
   • Do not punish for soiling pants.

Call Your Doctor 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 using this advice
• The resistance has not stopped completely after 3 months

Author: Barton Schmitt MD, FAAP

Copyright 2000-2020 Schmitt Pediatric Guidelines LLC

Disclaimer: This health information is for educational purposes only. You the reader assume full responsibility for how you choose to use it. The information contained in this handout should not be used as a substitute for the medical care and advice of your pediatrician. Listing of any resources does not imply an endorsement.

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