Positive relationships: Private matters on the potty

Q: We have a four-year-old who, according to his mother, tries to put off going to the loo at home. He won't go willingly at school either. As a result, he often poos his pants, and while he appears not be at all bothered, school staff find this hard to deal with - sometimes twice a day! The family's GP has simply said that he will grow out of it. Does anyone have any experience of this and of how we could help him to help himself?

Unfortunately, there are no easy answers to this problem, as it really does depend on the child himself and the reasons for his reluctance to use the toilet. These reasons have to be established first before any appropriate intervention can take place.

The difficulty is that going to the toilet is not just a 'physical' skill but is also influenced by personal feelings about the process. For example, I wonder how many adults don't like going to the toilet in a public loo?

The language we use also highlights how feelings of embarrassment can be linked with going to the toilet. The letter writer has chosen 'poo', which is often used when talking to children, but what words do we use when talking to adults? Do we feel comfortable with words such as poo, wee, number 2's and so on?

For most of us, in this society, going to the toilet is a very private act. In addition, while passing urine is accepted as more 'communal' for men, having a bowel movement is seen as private for both men and women - which, incidentally, means that little boys have to learn two ways of using a toilet!

In families, too, different attitudes exist. Some families have few boundaries, while others feel strongly about their privacy at these moments.

Practitioners, therefore, need to consider both a family's approach to toileting and the emotional 'atmosphere' around going to the toilet itself.

For these reasons, I want to first consider toilet training and the developmental changes that occur around this time, providing some hints as to why difficulties can arise later.

DEVELOPMENTAL CHANGE

Around the middle of the second year, most children have the momentous transition of being able to recognise themselves in a mirror, and so the understanding of a separate 'self' takes on another dimension. Children around this time also begin to be able to point to parts of their own body and so are becoming more 'body aware'. They are also often walking with greater confidence and skill and beginning to say several words.

This body awareness often coincides with the greater maturation of complex physiological systems which control bladder and bowel function, which is why trying to 'train' children before they are developmentally ready can be counterproductive and lead to later resistance and/or anxiety.

In addition, this new body awareness brings with it the beginnings of understanding that the child is 'visible' to others and their actions are judged as 'good' or 'bad'. The process of toileting, therefore, coincides with early feelings of shame/embarrassment. Parents' and practitioners' reactions to both 'product' and process may influence how the child feels about their bodily functions.

Overall, a child is ready for toilet 'training' when they:

- are aware that something is going on (indicating that bodily systems are mature enough) - for example, a child can suddenly become 'still' while playing

- may take an interest in others going to the toilet or wanting to use the potty/toilet

- can stay dry for longer periods (again, showing a maturing physical system)

- are able to walk short distances

- are able to sit upright steadily

- can follow instructions and be interested in the process

- have the ability to help with clothing by pulling, tugging, etc.

Often it is not until children are around 16 to 18 months of age before all the necessary skills are in place, although obviously individual children vary considerably. The whole process itself takes time, with control of the bowel at night happening first, then bowel control in the day, then control of passing urine during the day and then finally control of passing urine at night. Boys may take longer to become toilet trained than girls.

WHAT ABOUT THIS LITTLE BOY?

There are several points arising. First, the practitioner says that the child is four and has been seen by the doctor. However, 'pooing' in the child's pants is often not seen as a potential problem until a child is four, and so when the child was taken to the doctor and how long the problem has existed is important. Also, have there been any stressful experiences in the child's life, such as a new baby or house move? Sometimes a 'well-trained' child will regress as they try to deal with these new situations.

Second, taking into account the comments, the practitioner will need to find out when and how the child was toilet trained. This has to be done with great sensitivity as the parent must not be made to feel that they are being criticised.

Unfortunately, toilet training is an area when competition can occur between parents, taking pride at how soon their child can achieve these skills. The situation is not helped by the plethora of advice regarding toileting, which is often focused on how quickly to do it.

However, knowing at what age toileting began and in what circumstances will provide a picture of whether this process was fraught or relaxed and sensitive to the child's reactions and signals. The practitioner will also need to know what words are used for these functions, to ensure continuity between home and setting.

Third, this type of soiling can be linked with constipation, and if a child has had a painful experience before when opening their bowels, this can leave them very reluctant to go to the toilet and they then soil their pants.

Fourth, the parents and practitioners will need to think about the child's attitude to actually going to the toilet, especially when we think of all the skills it involves - managing their clothing, cleaning themselves, shutting the door, being inside a small space. Many children are afraid initially of falling into the toilet and/or of being 'flushed away', or are frightened at the sound of flushing. Adults must also remember that very young children are unable to 'hang on' for long, so when they need to go, it has to be quick!

The practitioner also says that the boy seems not to be bothered by going in his pants. This raises questions as to whether he finds passing his stool this way more comfortable, which may indeed suggest a painful bowel action in the past. Notice must also be taken of the appearance of his stool and whether his diet may or may not be helping the situation.

What both parents and practitioners need to remember is to keep everything very low-key, with gentle reminders that poos need to go in the toilet when his accidents happen. Neither punishment nor 'bribes' are helpful. He will regain his trust and confidence in the whole process if parent and practitioner encourage him to come to them when he gets a 'feeling' in his back passage or bottom, and reassure him that they will take him straight to the toilet.

How this child perceives the whole process is the key to this situation and, in addition, now that the child has reached four, it would be helpful to again seek the advice of the doctor, who may also recommend speaking to a health visitor.

Maria Robinson is an early years consultant and author of 'From Birth to One' and 'Child Development from Birth to Eight: A journey through the early years '(Open University Press). Her Nursery World series on child development can be bought online at www.nurseryworld.com

If you have a behaviour query for Maria Robinson, please e-mail it to: annette.rawstrone@haymarket.com, or write to the address on p13

REFERENCES

- American Academy of Family Practitioners, 'Nonretentive Encoparesis and Toilet Training Process Refusal', at http://www.aafp.org/online/en/home.html

- Klasen, TP, Kiddoo, D, Lang, ME, Friesson, C, Russell, K, Spooner, C, Vandermeer, B, (2006), The Effectiveness of Different Methods of Toilet Training for Bowel and Bladder Control, AHRQ Publication No. 07-E003, December (University of Alberta, Canada)

- Luxem, Michael, 'Behavioral toilet training in early childhood: research, practice and implications', in J Dev and Behav Ped, 15(5) 1994. 370-378.

- Ozturk, M, Faruk, O, Kisioglu, N, Mustafa Demirci, M, Altunta, I, Kutluhan, S, Dogan, M, (2006), 'Bladder and Bowel Control in Children with Cerebral Palsy: Case-Control Study', in Croat Med J. 6;47:264-70

- Ross, Tony (1988), I want my potty - a truly funny and timeless book for very young children starting out on this journey!