Adam is an adorable two-year-old boy with an awesome, loving, supportive family. He is the middle child of three, and is just beginning to show interest in using the toilet. He handles “number one” like a champ and gets lots of kudos and high-fives from his parents and older brother for using the potty. However, he initially refused to poop on the toilet.
With lots of encouragement, he finally manages to move his bowels while sitting on the commode. After that event (and it WAS an event, with much praise and fanfare), he refuses an encore, with tears and tantrums. Worse, his normal bowel habit of daily or twice-daily stools changes. He starts going several days between stools and then begins complaining of tummyaches and wetting his training briefs again.
What’s going on? Why all of a sudden is he taking two steps back in his toilet training progress? Is there a link between toilet training and constipation?
Yes, there is. Constipation and stool withholding are commonly seen during the toilet-training process. More commonly seen in boys than girls, it’s felt that stool withholding is a form of assertion of control. Toddlers in the two-to-three-year-old age range are in the control-and-competency developmental stage which I affectionately call the “terrible threes.”
Broken down to its basics, three-year-olds are learning that they can have control over themselves and their environment. It is a very important developmental task and is often difficult for parents. This is where I counsel parents to pick their battles and cheerfully load their toddlers up with age-appropriate choices (red shirt versus blue shirt, toast vs waffles for breakfast, book before nap or straight to nap, bath before or after bedtime snack, etc). Here’s a great book on navigating this age and stage.
Toilet training is the ultimate struggle for control. This is one where the toddler holds all the cards. He CAN choose and he WILL choose whether he wants to pass urine and stool into the commode or into his diaper/briefs.
Working backwards with Adam’s worried Mom, we figured that what probably happened was that when he pooped on the commode the sound and the splash startled and scared him. Put yourself in his place, right? If you’re not expecting it, that echoing depth-charge sound from deep inside this big cold white thing, coupled with a sudden splash of cold water on his bottom, were probably pretty scary!
After that experience, although he got positive reinforcement from his family, he wouldn’t really be eager for a repeat performance. Feeling pushed into doing something again that was scary to him would have triggered every control urge in his three-year-old heart. Digging in his heels in typical toddler fashion, he took that control and ran with it.
Not only did he not want to poop on the commode, now he didn’t want to poop AT ALL. After withholding stool for a day or two, the stool would have become hard and possibly painful to pass. That would have negatively reinforced the experience of pooping which will make the process worse.
Constipation (whether or not it’s caused by stool withholding) causes lower abdominal pain and can interfere with urinary urge and control as well, so he starts having trouble staying dry. Poor Adam, and poor Mom and Dad! Everything seems to be falling apart.
I’m so happy Adam’s mom brought him to see me (and Dr. Ted, who was very helpful). A quick check showed Adam was very healthy and had no signs of illness.
Our plan for Adam started with a full stop on toilet training. If Adam wanted to use the toilet, by all means go for it, but no pressure. He was in control.
Next we needed to relieve his constipation which required him to unlearn the “pooping hurts” conditioning. To do that, we used mineral oil, one teaspoon in yogurt or pudding every morning. Plenty of fresh fruit and water to drink. Mom would gradually increase the mineral oil every few days until he’s back to one or two soft stools daily. Mineral oil softens and lubricates the stool so that it’s difficult to withhold and easy to pass. (Don’t give mineral oil alone, always mix it in creamy food.)
After the tummyaches and constipation were gone, I suggested Mom and Dad take Adam shopping for a potty chair of his own. With no water in the potty chair, there’s no splash to bother him. Letting him pick it out helps him take ownership and control of the toilet training process.
Once he was able to move his bowels sitting on the potty chair, he would empty it himself. Dumping his poop in the commode would get him accustomed to the sound and splash it makes in a funny and non-threatening way.
Toilet training is tough for both parents and toddlers. Beyond the bodily control required (which is a milestone of physical development), toddlers and parents must negotiate the minefield of personal control that is part of the larger developmental stage.
In the larger scheme of things, I encourage parents to relax and take the long view. If you make toilet training is a battle, you won’t win. Your child holds all the ammunition, and pushing too hard can set your kiddo up for some health consequences. She will learn to use the commode at her own pace, and I promise she won’t go to college still wearing pull-ups.
Talk to your child’s doctor if you’re having trouble with toilet training and constipation. The sooner it’s addressed, the less it will disrupt your efforts to guide your child through this important learning process.
QUESTION: Did your child have trouble with toilet training and constipation? What worked for you?