A speech therapist friend of mine reached out a few weeks ago to ask for advice for a family with a five-year-old child who refused to poop on the toilet.
I get this question a lot, and, frankly, it’s part of the reason I started this newsletter and wrote The Constipation Game Plan. As a physical therapist, I can teach kids all about how to sit on the toilet, relax their pelvic floor muscles, and use their belly muscles to bear down to push out a poop. But when I evaluate a kid who is refusing to sit on the toilet to poop, that takes me a little further out of my PT scope of practice. Instead, I have to rely on what I’ve learned from my OT friends, behavior therapists, psychologist, and other parents to come up with a plan.
So, what to do?
Step 1(A):
For many of the kids I work with, the first step is, well, to take a step backward. If a child is refusing to poop on the toilet, then they are not potty trained. If they are not potty trained, then this means they should not be wearing “big kid undies”. They should go back to pull-ups.
While this can be super demoralizing for kids and parents alike, I think it's super important that your child feels comfortable pooping whenever and where ever they get the urge. Here's what to say to your kid:
“You know, the most important thing is that you get your pee and poop out of your body. If you don’t, then your poop can get stuck, and that could make you sick. Pooping on the toilet is hard and scary for you! So, instead of making you hold your poop until you get home and can get into a pull-up, we are just going to let you wear pull-ups all day long. That way, whenever your body tells you it’s time to poop, you poop!”
For now, you should just celebrate every time your child has a BM. Give them a great big signal that you don’t care if they poop in a diaper, a pull-up, or in the toilet … you’re just happy their poop didn’t get stuck in their body!
Step 1(B):
At the same time as you’re teaching your child about the importance of getting poop out, you should be working with your pediatrician to treat your child’s constipation with laxatives. And yes, your poop-witholding child is constipated. You can read The Constipation Game Plan to learn why, but, for now, just trust me.
Treating the constipation is essential, because you want to be able to tell your child that having a BM isn’t going to hurt them anymore. You also want to be able to set your kid up for success - once you do get them sitting on the toilet again, the correct laxative (along with the timing of sitting and the child’s posture on the toilet) will help them have a BM quickly, so they spend less time on the toilet.
(Treating the constipation with laxatives usually involves a clean-out followed by a maintenance dose of medicine. I discuss these in detail in The Constipation Game Plan.)
Step 2:
Once your child knows that the biggest goal is getting the poop out, you can work on getting your kid on a schedule. Kids like routine. This goes doubly for the types of kids who typically hold their poop. So it’s worth taking some time to set up a toileting routine that can lead to some predictability in your child’s life.
You should set up this routine so the child knows when they are likely to have a BM. The easiest routine, and the one that seems to be the most successful for my patients, involves these steps:
- Take the prescribed laxative (or laxatives, if your doctor recommends a stool softener plus a stimulant laxative) at night before bed.
- In the morning, have your child eat breakfast (hopefully one that includes fruit) and drink 8-10 ounces of water.
- Do a few exercises after eating. Walk to the mailbox, go up and down the stairs five times, do some jumping jacks or jogging in place, or try my sun salutation video.
- About fifteen minutes after breakfast, as your child to try to have a poop. They’re in their pull-up, so just let them get into whatever position they need to be in to poop. You can tell them that their medicine, and their breakfast, and their exercise made it likely that their body needs to poop. Can they feel that?
If a morning routine is tough, try a similar routine after school or after dinner. The goal is that, after doing this for several days in a row, you can train your child’s body to have a bowel movement at approximately the same time of day, every day.
Step 3:
Once your child is on more of a routine, and trusts that BMs aren’t going to hurt, it’s time to try to get him or her closer to the toilet. This might mean redirecting your child to the bathroom to try to poop if they usually go to their room or hide behind the couch. Once they can poop in the bathroom, see if they can poop while squatting in the bathroom (if they usually stand or go on their hands and knees). Be sure to praise them every step of the way!
Every child is different, and at this point you are going to be the best expert on what to do next. What motivates your child? Once your child is successful pooping on the toilet, you should celebrate in a way that is very meaningful to your child. For my kid, it would be going to get ice cream. For others, it might be a new game or toy.
Step 4:
Once your child is pooping on the toilet regularly, you can get them out of that pull-up. But - please! - keep careful track of their BMs to ensure they’re not holding again. They will need to stay on their laxative routine as well as their daily BM routine (step 2) for a while, until they get to a point where having a BM on any toilet (not just the toilet at home) is a piece of cake.
So there you go - a four-step (or is it really five steps? Probably) plan to get your child pooping on the toilet. It’s important to recognize that each of these three steps is going to look and sound different in your home. It all depends on your child’s age, their cognition and communication skills, and their ability to listen to and respond to signals from their body.
If you have a child who is a toilet-refuser, or if you work with one, I really recommend you read The Constipation Game Plan. Getting a child to have a BM on the toilet is a major milestone! But it doesn’t mean the physiological consequences of withholding stool just go away. The sooner you read the book, the sooner your child will be on a path to feeling better.