By Steve Hodges, M.D.
The other day I received an email with the subject line “Toddler Potty Training Regression Inquiry.” A mom recounted that her daughter had initiated potty training at age 30 months and all went smoothly, but now, at 33 months, the girl is having daytime pee accidents and holding her pee and poop for many hours.
“I can’t tell if this is just a bit of a regression,” she wrote. “She eats an extremely healthy diet, is very active, and has had no life stressors/changes in the last month, so I am stumped.”
I’m not stumped! This is a classic case — not of “potty regression” but of the progression of chronic constipation. "Potty regression" is a misnomer, as misleading as three other toileting terms I'd like to see canceled: “potty refusal,” “not fully potty trained,” and “nighttime potty training.”
“Potty Regression”
“Potty regression” is typically used in reference to a child who has been toilet trained for months or years and suddenly starts having pee or poop accidents. Parents want to know: Why is my child going backward?
The implication is that the child has somehow forgotten, lost, or disregarded skills previously mastered. Often, the “regression” is attributed to a psychological stressor — the birth of a sibling, starting a new school, moving to a new home.
For example, a Washington Post columnist advises parents to “get ready for regression (peeing in underwear) at times of stress, separation and other difficult moments.” She adds: “This is not abnormal, and it is not a problem.”
Actually, the onset of persistent accidents is abnormal and is a problem. Certainly, it’s a fixable problem, but the scenario warrants treatment, not dismissal.
In the case of pee accidents, a pile-up of stool has stretched the rectum such that it is encroaching up on the bladder’s territory (the two organs reside side by side) and aggravating the bladder nerves. The bladder contracts suddenly and forcefully, emptying without warning, even before it has filled.
You know the expression “You’re getting on my nerves”? That is literally what’s happening.
Parents, understandably, are baffled that their potty-trained child has started having accidents “out of the blue.” But it's very likely that before the accidents began, the child had milder, more subtle symptoms of chronic constipation, such as the sudden, overwhelming urge to pee, the incessant need to pee, or extra-large poops. These symptoms, falling short of accidents, likely went unnoticed or disregarded.
Sometimes, wetting can start many months or even years after a child was toilet trained. It just took a while for a critical mass of poop to accumulate and stretch the rectum enough to trigger accidents. Many children start having accidents in kindergarten — not because the transition to elementary school is "stressful" but because the restroom is down the hallway rather than adjacent to the classroom. Rather than ask the teacher for permission to use the bathroom, the child develops the habit of suppressing the urge.
What about “regression” to poop accidents? Encopresis is just a different symptom of the same enlarged rectum. In this case, the stretched rectum has lost sensation and tone (think of a sock that has lost its elasticity). So, the child does not feel the urge to poop, and the rectum does not have the oomph to fully shovel out the day’s load. At some point, so much poop piles up that it just drops out the child’s bottom, without the child even noticing.
This is the point at which parents become super frustrated. I hear: “She knows darned well how to poop on the potty. She’s been doing it for over a year.”
She still knows how. But she’s just not getting the signal. Treating the constipation appropriately will restore the rectum’s normal function.
“Potty Refusal”
So-called “potty refusal” is often used in two contexts: a child’s “refusal” to toilet train and “refusal” to poop on the toilet once trained. The implication is that the child is resisting cooperation — willfully, unreasonably, inappropriately, stubbornly.
“My 5-year-old REFUSES to poop on the toilet!!!” one mom emailed me.
“My 4-year-old [is] no longer in preschool because of her refusal to sit on a toilet . . . She is strong-willed and has picked the potty as her primary battle,” a mom asked a Washington Post parenting columnist. “What should I do?”
Even some physicians have adopted the term, fancying it up as “stool toileting refusal” and “toileting refusal syndrome (TRS)” in published studies.
Usually, this alleged defiance is explained in psychological/behavioral terms. For example, the child is said to be exerting developmentally appropriate independence. “Refusals are about the natural need for control,” asserts Pull-Ups.com.
Or, the child is said to be revolting against excess parental pressure to potty train. As the Post columnist wrote: “Humans don’t like to be bossed around . . . Your daughter is so stressed from the coercion that she is losing touch with her toileting impulses.”
Let me offer another explanation: When a toddler resists using the toilet, it is because the child is not developmentally ready to do so. And when a 4-year-old or 7-year-old resists, it is almost certainly because the child is constipated, in which case pooping is painful and/or the rectum is so stretched the child no longer feels the urge to poop. (That toddler might be constipated, too; many 2-year-olds are constipated before they start training.)
In neither case is the word “refusal” appropriate. I mean, if you handed a 2-year-old a bicycle and the child resisted riding it, would you describe the child as “refusing” to ride a bike? If you instructed a 3-year-old to read Star Wars Jedi Academy and the child tossed it aside, would you describe that as “reading refusal syndrome”?
Of course not. The kid just wasn’t ready! Promises of M&Ms or stickers or an awesome new bike helmet will not change that fact.
In many cases, parents simply decide — based on the child’s age or a preschool’s September deadline, rather than the child’s maturity level — that a child should be using the toilet. And when the parents’ plans go awry, it’s the child who is deemed unreasonable, a.k.a. “refusing.”
In a published report, German psychiatrists describe toileting refusal as “a common disorder in toddlers, defined by use of diapers and refusal of toilet for defecation.”
A disorder? The vast majority of toddlers are too immature to toilet train in the first place, as I explain in “The Problem with Preschool Potty Training Deadlines.” Labeling their “refusal” to poop on the toilet a “disorder” or a "syndrome" is silly and reinforces the unrealistic expectations our culture has set.
If adults simply backed off and allowed each individual child to set their own potty-training timeline, this type of “refusal,” along with the frustration that stems from it, could be avoided.
While I advocate a laissez-faire approach to toilet training, I take the opposite approach when an older preschooler — say, at least 3 ½ or 4 years old — regularly pees on the toilet but has difficulties with, or “refuses,” pooping. Most of these kids are chronically constipated and should be treated with enemas and/or laxatives. Nonchalance will not clear out a clogged rectum.
Yet parents are often advised to “say nothing more about the toilet,” as the Post columnist advised.
Likewise, in an article titled “Is Your Toddler Straight-Up Refusing to Poop in the Toilet? Join the Club,” an economist and parenting author urges parents to chill out. “Like many experiences of early parenting, this too shall pass. It might take a month—honestly, it might take six—and in the moment, it will be frustrating (trust me, I know). But eventually your child will poop in the toilet.”
If only you could make this assumption! I have an entire medical practice that demonstrates otherwise.
What these folks are missing is that chronic constipation, left untreated or under-treated, often progresses to encopresis and enuresis. I have loads of teenage patients with these conditions, and in most cases, their difficulties were apparent by age 3. But their parents were told, “This too shall pass.”
Interestingly, several published studies connect potty “refusal” with constipation, but the use of the term “refusal” obscures the obvious lessons that should be gleaned from these studies.
For example, a study published in Pediatrics, tracked 482 children who were ages 18 to 30 months at the start of the study, and checked in with their parents every 6 months until the kids were toilet trained. Among the findings:
• 106 of the children “experienced at least 1 month of stool toileting refusal.”
• “Refusers” trained at a later age than the rest of the group.
• 50% of the children who trained between ages 3 ½ and 4 experienced “refusal.”
• 61 kids developed stool withholding during toilet training, and 80% of them were “refusers”
To which I say: Of course! All this demonstrates is that many children are being toilet trained too early and as a result are becoming constipated. My own research has found that children trained before age 2 have triple the risk of developing chronic constipation and enuresis than children trained between 2 and 3. This does not mean 2 ½-year-olds are in the clear. Not at all. Plenty of 30-month-olds lack the maturity to toilet train and develop constipation. But the odds are particularly high for kids under 24 months.
As for those “refusers” who trained later than everyone else: These are just kids who were chronically constipated when toilet training began. Attempting to toilet train a child whose rectum is clogged and who already is in the habit of delaying pooping is a recipe for frustration all around.
In fact, another study published in Pediatrics makes this exact point: Among nearly 400 children tracked, over 24% developed “stool toileting refusal,” and these children were defined as having hard bowel movements and painful defecation. And guess what? 93% of them demonstrated constipation before the onset of STR. (Italics are mine.)
These children started toilet training with a condition that makes toilet training impossible. So, why are we labeling them “refusers”?
“Not Fully Potty Trained”
Parents often tell me that their child is “not fully potty trained” or is “pee trained but not poop trained.” When I probe further, I learn what they really mean: Their child is either having daytime accidents (pee or poop) or that the child has no trouble peeing on the toilet but resists pooping on the toilet.
Both situations are red flags for chronic constipation, and neither situation has anything to do with “training.”
As I’ve explained, when a child’s rectum is stretched, the rectum loses tone and sensation, so the child can’t properly sense the urge to poop. And many children who've experienced painful pooping understandably want to avoid it. Instructing the child to “poop when you feel the urge” and “listen to your body” won’t help when the child cannot feel the urge and/or associates pooping with pain.
Yet many preschools view accidents as a sign of inadequate instruction and often send children home to “work more on potty training.” Some schools even tell parents the child is not welcome back at school “until she is fully potty trained.”
Potty training is not like driver’s training! Sure, in the first few days and weeks a child is using the toilet, instruction is helpful, particularly reminders to use the toilet as soon as you feel that urge. And, of course, you explain the basics: pulling down your pants, climbing onto the toilet, relaxing, letting it all out, wiping, washing your hands.
But kids who are ready to use the toilet and who are not constipated don’t need much coaching. Using the toilet comes naturally and quickly. If the child is having accidents three months later, training is not the issue.
“Nighttime Potty Training”
Parents in my clinic often ask when they should begin “nighttime potty training.” This term also comes up in posts by parents who are new to our private enuresis support group.
One mom wrote, “My daughter is 3 and finished daytime potty training half a year ago, and we just started nighttime training last month.” Another posted: “My 5-year-old refuses to poop on the toilet and sleeps with a pull-up since we just 'were working on getting her to poop on the toilet first' and then planned to night time train her.”
I’m guessing these parents get their cues from potty-training coaches and product manufacturers who push the false notion that you can teach a child to be dry overnight.
A while back I read 14 potty training books, several of which pushed the “night training” concept. One author tells parents: “It needs to be decided whether you’re going to just focus on daytime training or try to take your child out of diapers at night as well.” Another writes that “becoming dry at night requires a devoted effort on your part. Don’t shirk your parental responsibilities at this final hurdle!”
Product manufacturers pick up on this idea, insisting that if a child can “feel” the wetness overnight, this discomfort will prompt them to start staying dry.
Peejamas bills its absorbent pajamas as the “diaper alternative for nighttime potty training," asserting that “some kids simply grow a bit ‘dependent’ on the ease of their diapers.” The company's Kickstarter page puts it more bluntly: “Diapers are a crutch that only delay a child's ability to potty train at night.”
This is false, as I explain in “Nighttime Potty Training is Not a Thing.” In reality, dryness happens naturally, and if a child is not dry by about age 4, the child probably is constipated. (An x-ray will answer the question definitively.) You can’t cajole a child into overnight dryness by withholding diapers so that the child feels wet.
Peejamas states that “If your child is getting the hang of daytime potty training, but still struggling to hold their urine at night, nighttime trainers may be the perfect solution.”
A better solution is to treat the underlying cause of the enuresis.
I'm generally not inclined to serve as the language police. But when it comes to toileting issues, many of our common terms — terms we give little thought to — reinforce misconceptions and ultimately deprive chronically constipated children of the treatment they need.