Stool Toileting Refusal (STR)
By Dr Brown
One of the more frustrating things that parents can go through with their child is when the child refuses to have a bowel movement on the toilet – “Stool Toileting Refusal” (STR). This can happen in typically two patterns:
Either way, these children have accidents and soil themselves, or they hold and hold until they have a diaper placed on them (usually for bedtime and then poop in the diaper).
In scenario 1, there seems to be something “weird” or “taboo” about pooping and they just flat out refuse to poop on the potty. Sometimes pooping (sounds, feelings, etc) is just a little too overwhelming for a toddler.
Scenario 2 is usually precipitated by the passage of a hard stool at some point, and the child fears that it’s going to hurt again next time they have to poop. In this scenario, they intentionally hold the stool, not realizing that the longer they go without passing a stool, the worse it’s going to be – creating a vicious cycle! The longer the stool “grows” the more it stretches out the rectum leading to further problems. This is an all too common scenario that leads to what we call “overflow” constipation. This leads to passage of loose watery stool around the hard stool that may paradoxically look like diarrhea to the parent. This is fixed by getting the hard poop out so it doesn’t cause this continual blockage and leakage of loose poop into the pants. It’s very hard for a child to control these liquid soiling accidents as the muscles that control their bowels get over-stretched. There is a great video that discusses this concept on YouTube called "The Poo In You" - GI Kids, Colorado– the video is about 5:45 and helps parents understand this perplexing problem. Additionally this build-up of stool in the rectum (which sits right behind the bladder) can lead to urine accidents also.
Please see our web page "Abdominal Pain" and refer to the section on "constipation" for discussion of an approach to help this overflow constipation problem.
What to do:
Allow your child to wear a diaper to have a poop until he or she gets this figured out! Although it may seem like you’re taking 1-2 steps backward, it’s much better than taking the 5 steps backward if you get into the overflow constipation problem listed above. Put a diaper on the shelf, counter, whatever, and ask your child to tell you when its needed. You may also need to suggest “we put a diaper on” if you see your child starting to sneak in the corner or begin to strain. Put the diaper on, walk away, and let your child do their business. When he or she is done, calmly change them, tell them thanks for pooping and be done with it. It’s probably best not to use terms like “stinky diaper” or “yuk” or whatever. Just be done with it. Also as frustrating as it can be, please do not make your child feel ashamed or punish him or her – it only leads to further stress on the child and can make things worse.
This approach was evaluated in a study in 1997 with these results:
All of the children for whom advice was requested were wearing underpants but given a diaper to defecate. The initial intervention used on 27 children. This approach was successful in 25 of the 27 children. Two children began having bowel movements in the toilet in less than 1 week, 9 within 1 month, and 14 between 1 and 3 months.
By Dr Brown
One of the more frustrating things that parents can go through with their child is when the child refuses to have a bowel movement on the toilet – “Stool Toileting Refusal” (STR). This can happen in typically two patterns:
- A child successfully learns to use the potty to urinate, but refuses to have a bowel movement on the toilet.
- A child is successful in potty training for both urination and bowel movements, but at some point decides to not use the potty for a bowel movement.
Either way, these children have accidents and soil themselves, or they hold and hold until they have a diaper placed on them (usually for bedtime and then poop in the diaper).
In scenario 1, there seems to be something “weird” or “taboo” about pooping and they just flat out refuse to poop on the potty. Sometimes pooping (sounds, feelings, etc) is just a little too overwhelming for a toddler.
Scenario 2 is usually precipitated by the passage of a hard stool at some point, and the child fears that it’s going to hurt again next time they have to poop. In this scenario, they intentionally hold the stool, not realizing that the longer they go without passing a stool, the worse it’s going to be – creating a vicious cycle! The longer the stool “grows” the more it stretches out the rectum leading to further problems. This is an all too common scenario that leads to what we call “overflow” constipation. This leads to passage of loose watery stool around the hard stool that may paradoxically look like diarrhea to the parent. This is fixed by getting the hard poop out so it doesn’t cause this continual blockage and leakage of loose poop into the pants. It’s very hard for a child to control these liquid soiling accidents as the muscles that control their bowels get over-stretched. There is a great video that discusses this concept on YouTube called "The Poo In You" - GI Kids, Colorado– the video is about 5:45 and helps parents understand this perplexing problem. Additionally this build-up of stool in the rectum (which sits right behind the bladder) can lead to urine accidents also.
Please see our web page "Abdominal Pain" and refer to the section on "constipation" for discussion of an approach to help this overflow constipation problem.
What to do:
Allow your child to wear a diaper to have a poop until he or she gets this figured out! Although it may seem like you’re taking 1-2 steps backward, it’s much better than taking the 5 steps backward if you get into the overflow constipation problem listed above. Put a diaper on the shelf, counter, whatever, and ask your child to tell you when its needed. You may also need to suggest “we put a diaper on” if you see your child starting to sneak in the corner or begin to strain. Put the diaper on, walk away, and let your child do their business. When he or she is done, calmly change them, tell them thanks for pooping and be done with it. It’s probably best not to use terms like “stinky diaper” or “yuk” or whatever. Just be done with it. Also as frustrating as it can be, please do not make your child feel ashamed or punish him or her – it only leads to further stress on the child and can make things worse.
This approach was evaluated in a study in 1997 with these results:
All of the children for whom advice was requested were wearing underpants but given a diaper to defecate. The initial intervention used on 27 children. This approach was successful in 25 of the 27 children. Two children began having bowel movements in the toilet in less than 1 week, 9 within 1 month, and 14 between 1 and 3 months.