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Potty training: Some kids call for deeper understanding

Understand the barriers

It’s only natural for parents to become jealous when they hear about potty training prodigies who make their final poop in the pants at age two. According to The New York Times, the average age that children nowadays master the art of independent toileting is between 36 and 42 months. But what if your Pre-K-aged child still insists on diapers and your home front has become the Clash of the Commode? Where do parents turn when they truly believe they will one day have to send their child off to college with a box of pull-ups?

Rika Alper, a Developmental Psychologist in Montclair, NJ, often gets distressed calls from parents whose four-year-olds are resistant to potty training. The first thing she tries to do is reassure the parents that it will happen. Yes, there are children whose severe disabilities impede independent toileting, but the vast majority of kids go to Kindergarten in big boy or girl underwear. How do parents help their late bloomers?

Maybe your child isn’t just being stubborn; perhaps there are some bigger issues at play – be it anxiety, a sensory processing disorder or another special need. For children suffering from anxiety, the fear may not be about the toilet itself. Rather, they may have fears that impact their diets. When a child won’t touch foods that are red or green, or the insistence of sameness restricts a child to a diet of plain noodles, it affects the digestive tract. This low-fiber diet may lead to constipation or painful bowel movements. And it only takes a handful of painful pooping episodes for trauma to build up and hamper the ability to use the toilet.

“Freud did the world a disservice introducing the notion of anal retentiveness or withholding as the explanation for toilet-training problems,” Dr. Alper says. “People don’t understand that when a child’s constipation develops into a condition of impacted bowels, he’s not trying to withhold. He’s trying not to be in excruciating pain.”

Low muscle tone can also affect potty training. After all, the ability to sense when the bladder is filling up, to clench the muscles that hold urine in, and to sit on a toilet and squeeze all require abdominal strength. So Dr. Alper might advise doing sit ups to help those patients strengthen their abdominal muscles.

For children who are hypotonic, or not responsive to sensations, Dr. Alper recommends taking the diaper off completely, since the diaper reduces the feeling of wetness. (And soggy pants are a great motivator to using the toilet.) A child may not respond to a slightly damp diaper, but will likely notice urine dribbling down his or her leg.

The issues surrounding potty training are as varied as the children themselves. For some, the sound of the flush is scary. For others, they’re afraid of falling into the toilet. Dr. Alper worked with an Asperger’s boy who insisted on using diapers because he was afraid that if he peed in the toilet, it would go all over the room. It did, because he had problems aiming.

Take it step by step

Okay, you’ve determined what the issues are. Now what? Dr. Alper urges parents to break the process down into micro steps. She equates this with learning how to swim. Do you ease a child into the pool toe by toe, or just drop them in the deep end and hope for the best? “For kids with issues,” says Dr. Alper, “dropping them in the deep end is often a disaster.”

Though it may seem obvious, she counsels parents to move all things bathroom related into the bathroom. For example, encourage children to sit while they have a bowel movement, even if they’re wearing a diaper and they sit on the toilet with the seat down.

Dr. Alper had a four-and-a-half-year-old patient with horrible anxiety, low muscle tone and anal fissures from a history of painful movements. He was able to poop in a diaper because of the familiarity of it, as well as the sensory feedback he got from having something wrapped around his waist and bottom. Plus, the compression of the fecal waste against his body provided a comforting pressure. So Dr. Alper worked with his parents to create a step-by-step process to get past it. First, they cut a hole in the diaper so that he could sit on the toilet while pooping in the diaper yet still have the bowel movement fall into the toilet. He needed the pressure of the diaper around his waist. Eventually he transitioned out of a diaper, but still wore a belt around his waist for the sensory feedback.

Rethink the reward system

We’ve all heard about the marvels of sticker charts, or the power of M&Ms. But for children whose unique circumstances pose a greater challenge to potty training, a reward system may actually be counter-productive. Because it’s one thing to give stickers every time a child brushes his or her teeth; there’s nothing painful or scary about it. But no child is going to walk over hot coals for an M&M, and that is what using the toilet may feel like to a child with anxiety or autism. So the reward becomes yet another thing that the child is failing to achieve.

That’s not to say encouragement is a bad thing, especially if the reward is intrinsic to the process. A few examples are:

  • “Way to Go” cards for children to look at while sitting in the bathroom. These could have smiley faces, or a few simple words like “You can do it!”
  • Special underwear as an incentive for getting out of diapers.
  • The chance to swim in a big kid pool.

Dr. Alper believes that if you’re offering the child a glimmer of hope, you don’t need additional reinforcements, since it’s intrinsically motivating for the child to know how to use the bathroom.  She often reminds parents that as bad as they may feel about their child’s resistance, the children often feel worse. “If anything marks you as a baby,” says Dr. Alper, “it’s the diaper. And to a four year old, being called a ‘baby’ is about the worst insult you can imagine.”

Peer pressure is a powerful motivator, and if the stigma of still wearing a diaper amongst a preschool crowd clad in Dora and Bob the Builder undies isn’t traumatic enough, children late to potty train can sense the disapproval of their teacher who may be annoyed to have to deal with a diaper, or clean up messes. So Dr. Alper works not just with the parents, but the children themselves to instill confidence that they will indeed become potty trained. “It’s a relief to them,” she says, “a feeling that they are on the right path.”

Back away from the fight

Parents with children late to toilet train are often at their wits end and patience may be hard to come by. But Dr. Alper tries to remind parents that potty training, like anything else, is a process. She encourages the parent who has been most entrenched in the process to back away and let the other parent take the lead. Or enlist the help of a babysitter, anyone who can help lessen the fight with the child.

A developmental milestone happens at around age two. Along with speech and long-term memory, children develop what is known as symbolic thinking. Which means that using the toilet has become much more than a simple motor process; it is layered with emotion. The less emotion parents can add to the process, the better.

Not until the paperwork is done

What is Dr. Alper’s biggest piece of advice? Don’t stop short of finishing the process. It’s not enough that a child may be out of diapers if his parents are still wiping him at age 9. If a child can’t use a public restroom, or go away to camp or have a sleepover because he can’t stay dry through the night, the job is not done. Dr. Alper defines toilet training as complete independence with all aspects of toileting. Just remember, potty training is not a lost cause.