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PEDIATRICS Vol. 113 No. 6 June 2004, pp. 1809-1810

COMMENTARY

Understanding Toilet Training Difficulties

David R. Fleisher, MD

Department of Child Health
University of Missouri School of Medicine
Columbia, MO 65212

Toileting skills are acquired through 2 simultaneous, reciprocal processes: toilet training (what parents do to help their child toward socially appropriate, self-sufficient toileting) and toilet learning (what a child thinks and does while learning the mores of elimination behavior, how to recognize sensory signals, how to choose whether to void, and how to control anal and urethral sphincters in implementing that choice). This learning process can be derailed, resulting in functional disorders of elimination.

In this issue of Pediatrics, Schonwald et al1 infer that toilet training difficulties are associated with difficult temperament traits. Although constipation was more prevalent in their patients than in their normal control group, constipation nevertheless affected 55% of the latter. This result begged the question: Does constipation also contribute to toilet training difficulties, or is it a secondary epiphenomenon? In this month’s Pediatrics Electronic Pages, Blum et al2 confirm that constipation is contributory to the type of difficulty referred to as stool toileting refusal rather than a result of it.

Although constipation is an important element in the pathogenesis of stool toileting refusal, not every young child with painful defecation becomes averse to the toilet, and not every child who is averse to the toilet has experienced painful defecation.3 Other factors such as anxiety may interfere with toilet learning.4 Its sources may include fear of anticipated pain, conflict with parents around toileting, and emotional traumas.5 Toileting anxiety may cause pelvic floor dyssynergia,6,7 which impedes relaxation of the pelvic floor necessary for efficient voiding of stool and/or urine.

Another factor predisposing a child to toileting anxiety is the animism of early childhood.8,9 Piaget10 discovered that young children believe that inanimate objects (eg, formed stools) are alive and willful. If a 21/2;-year-old has never experienced anal pain or fear related to defecation, the child and his or her bowel movements "get along"; the child doesn’t feel threatened, and toilet learning is easy. By contrast, if that child passes a hard stool that causes an otherwise insignificant anal fissure, he or she suddenly feels unexpected pain in a part of the body that cannot be seen during a bodily function that is not felt to be entirely under his or her control. From the child’s point of view, "poo-poos" can be nice or scary. This animistic fear may make a child unwilling to try a new way of defecating, who will instead promptly request diapers so that he or she can stool in a way that is familiar rather than having to attempt something new. An empathic appreciation of the child’s way of thinking is important, because only the child can feel the urge to stool and effect defecation: no one else can do it for him or her.

Parents need to understand that toilet training differs from training in most other areas of behavior, because they cannot oblige their child to perform bodily functions their way.

Voiding and eating are bodily functions that are controlled by the child. If frustrated parents’ demands are met with their child’s mounting stubbornness, the chances of getting the child to cooperate diminish, and the possibility for abuse increases. Therefore, leadership by the parent or clinician (whether it’s applied during normal toilet training or during management of toileting difficulties) is probably most effective if it is noncoercive and based on an appreciation of the child’s feelings and cognitive level. We cannot cure functional disorders of elimination; only the child can do that. Our task is to facilitate the child’s efforts by doing what is helpful (eg, consistent administration of effective stool softeners until defecation is no longer worrisome to the child) and avoiding coercive measures that exacerbate conflict and anxiety.

Functional disorders of defecation are common and often difficult to treat. Their management needs a rational, scientifically sound basis. Unfortunately, many current recommendations are unproven and contradictory. Some experts recommend enemas for children with fecal retention and soiling11–13; others advise against rectal intervention in favor of orally administered laxatives.14–16 Some recommend obligatory toilet-sitting on the assumption that habitual defecation can be conditioned17; others are skeptical of toilet-sitting when the child doesn’t feel the urge to stool, especially if it creates conflict.3 Some prescribe diets containing foods that soften stools18; others prefer orally administered laxatives so as to avoid parent-child conflict around the bodily function of eating. Some view functional disorders of defecation as clinical clutter, unworthy of physicians’ efforts beyond ruling out organic disease, to be managed by ancillary caregivers. Others view the management of children with functional disorders of elimination as challenges worthy of the physicians’ best efforts.

We need to learn more about the interaction of physiologic, psychologic, and social factors5,15 in the pathogenesis and persistence of functional disorders of elimination so that management can be based more on what exists in the minds and bodies of our patients rather than on a variety of therapeutic customs.


   FOOTNOTES
 
Received for publication Dec 15, 2003; Accepted Feb 10, 2004.

Address correspondence to David R. Fleisher, MD, University of Missouri School of Medicine, One Hospital Drive, Columbia, MO 65212. E-mail: fleisherd{at}health.missouri.edu


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  2. Blum NJ, Taubman B, Nemeth N. During toilet training, constipation occurs prior to stool toileting refusal. Pediatrics.2004; 113(6) . Available at: www.pediatrics.org/cgi/content/full/113/6/e520
  3. Fleisher DR. Diagnosis and treatment of disorders of defecation in children. Pediatr Ann.1976; 5 :700 –722.[Medline]
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  11. Klish WJ. Functional constipation and encopresis. In: McMillan JA, DeAngelis CD, Feigin RD, Warshaw JB, eds. Oski’s Pediatrics: Principles and Practice. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999:1637–1639
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  17. Croffie JMB, Fitzgerald JF. Idiopathic constipation. In: Walker WA, Durie PR, Hamilton JR, Walker-Smith JA, Watkins JB. Pediatric Gastrointestinal Disease. 3rd ed. Hamilton, ON, Canada: Decker; 2000:838
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics




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