What is Toilet Training?

Toilet training is the acquisition of skills necessary for urinating and defecating in a toilet at a socially acceptable time and age. It is a heterogeneous process influenced by many physiological, psychological, social, and cultural factors. Complex muscular physiology regulates bladder and bowel function.¹ Because the infant central nervous system is not completely developed, the bladder empties involuntarily as a result of spinal reflexes approximately 20 times a day.² As children develop, they gain the ability to recognize that their bladder is full and to retain urine until it is appropriate to void. Defecation occurs once the rectum contains a sufficient volume of feces. As the rectum fills with feces from the colon, the rectum expands and the internal anal sphincter relaxes; anal pressure is reduced and the desire to defecate is felt. A combination of the relaxation of the external anal sphincter, bowel contractions, and an increase in intra-abdominal pressure achieved by straining results in defecation. The external anal sphincter can be voluntarily contracted if defecation is not appropriate.

An all-encompassing definition of “toilet trained” does not exist. For instance, there are no strict criteria stating how long a child must be bladder or bowel continent to be considered toilet trained and often the definition of success is dependent on the specific toilet training approach.³ In addition, it is unclear what components of the toileting process the child must accomplish independently, such as undressing and dressing, flushing the toilet, or washing hands, to be considered toilet trained.³ Western culture perceives the meaning of “toilet trained” to extend beyond the absence of bladder and bowel accidents and to include toileting in socially acceptable places, toileting in a proper posture, and complete toileting in a sanitary manner.⁴

Evolution of Toilet Training

In North America toilet training methods have oscillated over the last century (Table 1).³ In the late 1800s and early 1900s toilet training was considered a passive and permissive process and was primarily determined by parents. During the 1920s and 1930s a new generation of behavioral scientists emerged and toilet training was regarded as a rigid habit-training process, but it was still determined by parents. The objective of toilet training was to quickly alleviate the burden of infant wetting and soiling.⁵ In 1932 the American government publishedInfant Care and suggested that toilet training was to be completed by six to eight months of age.⁶ Training was coercive in nature; experts recommended the use of “soap stick” rectal conditioners to assist in bowel training. The importance of regularity and the scheduling of bowel movements were also stressed.

Table 1

Trends in recommended infant training methods extracted from three women's magazines from 1898-1948*.

By the 1940s it was hypothesized that rigid toilet training resulted in the failure to achieve bowel and bladder continence and that it may elicit behavioral problems.⁷ In addition, research had shown that children do not develop voluntary bladder and bowel control until approximately 9 months of age. Toilet training reverted to a child-oriented approach and parents were advised to begin toilet training once the child displayed interest in the process. In 1962 Brazelton developed the “child readiness” approach.⁸ This was followed by the Azrin and Foxx method that focused on structured behavioral endpoint oriented training.⁹ As toilet training moved from rigid parent-driven methods to child-oriented ones, the age at which toilet training was initiated increased.

Toilet Training Methods

The two primary toilet training methods used in Western societies are the child-oriented method and the Azrin and Foxx method. Both methods suggest that toilet training commence at approximately 18 months of age and that the child should be successfully toilet trained between 2 to 3 years of age.³ The two methods differ with respect to goal development, endpoints, and emphasis on the child's self-esteem. Additional toilet training methods include variations of operant conditioning and assisted infant toilet training. The toilet training methods are described in greater detail in Appendix H ^*.

Child-oriented. In 1962 Brazelton developed a child-oriented program that focused on gradual training.³ Brazelton described how he determined child and parent(s) was ready to begin toilet training. Toilet readiness is a combination of both child and parent willingness to participate in toilet training. The parent responds to the child's signals that the child is ready to begin toilet training. In addition, the parent must be willing to toilet train the child and be aware of training obstacles, such as the child attending daycare or any physical or mental disabilities the child may have.

The child must be physiologically and behaviorally ready to toilet train. Examples of child readiness include exhibiting some degree of bladder and bowel control, having the neurological maturity to co-operate, and voluntarily participate in toilet training. It is believed that these components are not developed until the child is approximately 18 months old.

To toilet train the child, the child should become familiar with his own chair and sit on it while fully clothed. Once co-operation has been established, the child may sit on the chair without a diaper. The next step is to empty the diaper contents into the chair while explaining to the child that this where eliminations go. Once the child understands the chair, the child can be encouraged to use it independently and can begin wearing training pants.

Azrin and Foxx. Behavioral analysis and structured behavioral training were popular in the 1960s and 1970s and were subsequently applied to toilet training. The Azrin and Foxx method emerged in 1971 as a parent-oriented method that emphasized structured behavioral endpoint training aimed at eliciting a specific chain of independent events by teaching the component skills of toilet training.⁹ Although the Azrin and Foxx method was specifically designed for achieving bladder continence, it has been adapted successfully for bowel control.

The Azrin and Foxx method described the first set of objective criteria parents could use to determine if their child was ready for toilet training.³ The component skills include both physiological readiness (having periods of dryness and being physically able to perform tasks related to toilet training) and psychological readiness (able to follow instructional skills).³ Physiological readiness assesses adequate muscle tone required for independent toileting. Tasks may include walking short distances, dressing, and sitting upright. Psychological readiness establishes if the child understands the instructions and is motivated to adopt independent toilet training. Examples of psychological components are pointing to body parts and imitating a task.³ By completing the majority of the pre-defined tasks, a child proves able to complete complex motor tasks beyond eliminating at the proper time.

The child participates by recognizing appropriate elimination stimulus. This is a four-step stimulus-control model that is executed by (1) increasing fluid intake, (2) scheduling toilet training time, (3) positive reinforcing correct behavior, and (4) over-correcting accidents.

The Azrin and Foxx method is rigid and intensive in nature. In a study of the Azrin and Foxx method, some children initially reacted negatively to timed toilet training by having temper tantrums when training was initiated.⁹ The authors noted this reluctance was overcome by providing immediate graduated guidance when a child did not respond to a toilet training step.

Operant conditioning. While the child-oriented and Azrin and Foxx method incorporate operant conditioning, basic operant conditioning techniques have been used to toilet train.¹¹ The goal of operant conditioning is to establish habits and proper behavior through positive reinforcement with rewards.¹² Common rewards for successfully eliminating in the toilet include parental affection, toys, and candy. Accidents can be negatively reinforced, often through punishment or a lack of positive attention.

Assisted infant toilet training. This toilet training method is used in China, India, Africa, South America, Central America, and parts of Europe; however, it is poorly researched.¹³ Assisted infant toilet training results in infants that are toilet trained at a young age. Simultaneous training of bowel and bladder control may begin between the ages of 2 and 3 weeks.⁵ When the infant has consumed a large meal or shows signs of eliminating, the infant is placed on the toilet or in a voiding position.¹⁴ The parent must learn the infant's elimination signals.¹³ For this reason, this method has been criticized as the “parent training” method, as the parents must be trained to recognize and understand their child's cues to eliminate.

When the infant is likely to void, he is placed in a special position and the parent makes a noise that the infant learns to associate with voiding. When the infant voids to the specific noise, he is rewarded, often with food or affection.⁵ As the infant is conditioned, he is expected to better communicate his need to void and to crawl on the parent to assume the voiding position. With the exception of positioning, the same process is used for bowel training. During the first year of life, infants are not punished for having an accident.

A second method used to train infants is a three-phase approach that establishes a relationship with the infant and the potty.¹⁵ During the first phase, the parent identifies the child's body signals associated with eliminating. When the infant is expected to eliminate, the parent directs the infant's attention towards the potty and the infant is placed on the potty. Eliminations within three minutes of being placed on the potty are positively reinforced. In the second phase the infants try to reach or grab the potty prior to being seated on it. The third phase establishes unprompted reaching for the potty prior to elimination.

Elimination communication. Recently, Western countries have witnessed an increased enthusiasm regarding toilet training infants. While similar to the assisted infant toilet training method used in Africa, elimination communication requires parents to learn to recognize their infant's body language, noises, and bowel and bladder rhythms to determine when the infant is about to eliminate. The infant is then placed over the sink, toilet, or a specially designed miniature potty and the parent makes sound similar to that of running water. It is recommended this method be started at birth.

Since 2005, many prominent North American newspapers and magazines have published articles describing and promoting elimination communication. The main cited benefits of this method are reduced diaper expenses, fewer disposable diapers polluting the environment, strengthened infant-parent bonds, and increased infant comfort. In addition to articles in the New York Times, Boston Globe, National Post, and People magazine, there are also a number of Web sites and internet message boards promoting elimination communication (www.diaperfreebaby.org; http://www.timl.com/ipt/; http://www.theecstore.com; http://www.natural-wisdom.com; ). The articles are anecdotal and feature testimonials by parents; they are not supported by references to research assessing the effectiveness of the methods described.

Current Recommendations

The American Academy of Pediatrics and the Canadian Paediatric Society have published similar toilet training guidelines. Despite the lack of empirical evidences supporting the toilet training approach, both guidelines recommend: 1) a child-oriented approach; 2) that children are not physically ready to begin toilet training until 18 months of age; and 3) that the child displays interest in the process. They also promote the use of a potty chair. Potty chairs can either be inserted into the toilet to create a smaller seat or be a small toilet for the child; they may help curb the fear of falling into the toilet. The Canadian Paediatric Society also recommends using a footstool to make toilet training more comfortable and make the child feel more secure and stable. Both guidelines state that toilet training is not a cookie-cutter process and must be adapted to the specific child.

American Academy of Pediatrics (AAP). The AAP guidelines strongly suggest a child-oriented approach to toilet training and that parents do not pursue toilet training until the child is behaviorally, developmentally, and emotionally ready to begin.¹⁶ The guidelines recommend that parents and pediatricians discuss toilet training methods and expectations at the child's 12- to 18-month visits. At the 2-year visit, the pediatrician is able to assess the readiness of the child and parents.

The first step of toilet training is to introduce the potty chair and allow the child to sit on it while fully dressed. The parents should make the potty chair constantly available, but not pressure the child into acknowledging or using it. Parents can also explain the purpose of the potty chair by placing stool in the potty. It is then recommended that the child be placed on the potty chair during the specific times when voiding is expected and the parent explains what is happening. Positive reinforcement should be delivered after successful use of the potty chair. If the child is not successful at toilet training and if the parent-child relationship is not secure, the guidelines recommend temporarily abandoning toilet training and focusing on repairing the parent-child relationship by partaking in enjoyable activities and re-establishing trust and cooperation. It may take several months or years to develop nighttime bladder and bowel control. If the child is school-aged and regularly wets the bed, professional assistance should be sought.

Canadian Pediatric Society (CPS). The CPS guidelines recommend a child-oriented toilet training method where the parents and caregivers set time aside for the process.¹⁷ The guidelines emphasize that there is no correct chronological age when toilet training should begin and that it may take several months or years to establish nocturnal continence.

At the child's 1-year visit, the physician should begin to educate the parent about the toilet training process and readiness should be assessed at approximately 18 months of age. Signs of readiness include: walking to the toilet, sitting stably on the toilet, remaining dry for several hours, following simple instructions, communicating the need to void, wanting to please parents or caregivers, and wanting to be toilet trained. After the child has expressed signs of toilet training readiness, the child should be placed on the potty chair while fully clothed. The child is then placed on the potty after voiding, followed by sitting on the potty for several minutes throughout the course of the day. Next, the child is put on the potty at specific times, such as upon waking, after meals, and before sleeping. At each stage, the child should be positively reinforced with encouragement and support as opposed to material rewards. Accidents should be handled in a supportive and patient manner.

If toilet training fails, it is most likely due to the child not being psychologically ready for training. The child should be returned to diapers for 1 to 3 months before toilet training is re-initiated. It is suggested that parents seek assistance from a general or developmental pediatrician if repeated attempts have failed or the child continues to resist training by age 4.

Factors Related to Toilet Training

A variety of factors may effect a child's training. Current clinical practice guidelines stress that children can be trained differently and that training methods should be adapted to each child. Some of the factors that impact toilet training include sex, age at initiation, culture, race, physical or mental handicaps, and previous toilet training attempts.

Sex. While boys and girls often show toilet readiness behavior at a similar age, it has been shown that girls begin and complete toilet training earlier than boys. ^{18 19}Schum et al. examined 267 children and found that girls and boys mastered toileting skills in a similar sequence; however, girls routinely mastered toilet training skills at a younger age.²⁰ It has been hypothesized that girls accomplish this task sooner because of reasons related to socialization and a desire to please parents. Also, girls are physically more mature than boys and have more advanced language skills, skills that ease toilet training.²⁰ Furthermore, boys may have the additional obstacle of learning to adopt separate postures for voiding and defecating.

Age at initiation. Parents are often unsure of what age to begin toilet training. Parents may over or underestimate the skill required to successfully complete toilet training; this may result in early or delayed toilet training and associated problems.

Over the last 30 to 60 years, the average age of initiating and completing toilet training has risen.^{1 21} Schum et al. conducted a literature review and found that children toilet trained in the late 1990s achieved bowel and bladder control approximately 12 to 15 months later than children trained in the 1950s (36 to 39 months versus 24 months, respectively).²⁰ An increased understanding of pediatric physiological development may partially account for this trend. Other hypothesized explanations include an increased reliance on diapers and the parents' perception that their child is too young to train, especially as the child-oriented approach is promoted.¹⁸ Delays in toilet training can result in an increased risk of infectious diseases spread by diarrhea and fecal contact among childcare facilities,²² and family stress, particularly as the child approaches kindergarten.

Recommendations suggest that a child be at least 18 months old before commencing toilet training.³ However, Schum et al. have suggested that toilet training readiness skills are not obtained until after the child's second birthday.²⁰ The authors determined that of 267 children, girls mastered only 2 of 11 toilet readiness skills by 24 months and boys were not proficient at any of the 11 skills until after their second birthday. Schum et al. found the median age for girls to commence toilet training was 25.5 months and for boys 30.5 months.¹⁸ They recommend that toilet training commence when a child is 22 to 30 months old.¹⁸

In a cohort of 378 children, Blum et al. found that toilet training was completed at a mean of 36.8 (range 22 to 54 months).²¹ Late toilet training (at least 42 months of age) was associated with a later mean age of initiating toilet training, lower language score at 18 months, stool toileting refusal, increased constipation, and hiding during toilet training. In a second study examining the same cohort of children, Blum et al. concluded that training children at a younger age, that is, between the ages of 18 and 26 months, resulted in a longer training duration; however, there were no adverse events (constipation, stool toileting refusal, stool withholding, or hiding during training) associated with early training.¹⁹

Constipation. Constipation has a reported prevalence in young children ranging from 0.3 to 28 percent. ^{23 24} In a retrospective chart review, Loening-Baucke found the prevalence of constipation in 4157 children of two years of age to be 4.5 percent. The prevalence in the first year of life was 2.9 percent and 10.1 percent in the second year. Partin found that the majority of constipated school-aged children presented with pain, impaction and severe withholding and recommended treating constipation in infancy in hopes to reduce the likelihood of developing chronic fecal impaction and soiling on older children.²⁵

Pediatric gastroenterologists from the North American Society of Gastroenterology and Nutrition define constipation as a “delay or difficulty in defecation, present for two or more weeks and sufficient to cause significant distress to the child.”²⁶ An international group of pediatric gastroenterologists defined functional constipation in infants and preschool children as “at least two weeks of hard, pebble-like stools for most stools, or firm stools two or fewer times per week, in the absence of structural, endocrine, or metabolic disease.” This definition is known as the ROME II criteria.²⁷

Being constipated can make defecation painful, and this may be one reason a child may resist toilet training and passing a stool. If a child passes a hard stool that causes difficulty or even an anal fissure, he suddenly feels unexpected pain. Fear of recurrence may make a child unwilling to try a new way of defecating (i.e. in a potty), and the child will continue to stool in diapers or pants. Since only the child can feel the urge and initiate defecation, the training method needs to be sensitive to the child's feelings and perceptions of the act.²⁸ Signs and symptoms of constipation include a reduced frequency of bowel movements (generally abnormal to have fewer than three bowel movements a week²⁹), hard consistency, presence of pain, stool withholding, blood while defecating, and the presence of rectal impaction or abdominal fecal mass. Blum reported that constipation contributes to stool toileting refusal, rather than being a result of it.²¹

Culture. Toilet training is approached differently among various cultures. For example, cultures that depend on disposable diapers tend to toilet train children at a later age. It has been suggested that the increased availability of disposable diapers has been linked to a delay in toilet training.¹

Abramovitch (2000) interviewed mothers in one of three Israeli ethnic groups: Moroccan, Kurdish, or Ashkenazi.³⁰ Moroccan and Kurdish mothers tended to begin toilet training at a younger age than Ashkenazi mothers (Moroccans at 1.19 years and Kurdish at 1.28 years versus 1.92 years by Ashkenazi mothers). The methods employed for toilet training were also different; Moroccan and Kurdish mothers adopted an early, permissive, symbiotic style, whereas Ashkenazi mothers practiced a strict toddler style that may be authoritarian in nature. Moroccan and Kurdish children were more likely to develop enuresis than their Ashkenazi counterparts.

Race and culture. Age at initiation and completion of toilet training appears to be partially explained by race. The Digo people of East Africa begin toilet training within the first few weeks of life and expect the infant to be reasonably well trained between the ages of four to six months.⁵ Compared to other races, African-American children were found to start and complete toilet training at an early age.¹⁸ African-American children began toilet training at median of 21 months of age and were trained by 30 months. In contrast, Caucasian children commenced toilet training at 30 months and were trained at 39 months of age. When surveyed, 50 percent of African-Americans felt it was important their child be toilet trained by the age of two, while only 4 percent of Caucasian parents agreed with the statement. A second study surveyed four cultural groups in the United States to determine their beliefs regarding healthy infant and child development.³¹ European American mothers stated children were toilet trainable at 28.1 months of age, where as Puerto Rican, African-American, and West Indian-Caribbean mothers felt children reached toilet training age between 20.2 to 22.2 months.

Physical, mental, behavioral, and developmental handicap(s). Toilet training children with mental or physical handicaps present its own unique set of challenges. Compared to toilet training healthy children, there are additional components that need to be taken into consideration, such as communication delays, sensory process difficulties, sensitivity to stimulation, limited ability to imitate, compromised motor planning, and preference for routine.³²

The CPS guidelines recommend that prior to toilet training, parents have their child assessed by a pediatrician to determine the obstacles associated with training a child with special needs.¹⁷ The CPS also calls for a comprehensive study to examine the effects and challenges of toilet training children with special needs.

Physical and mental handicaps such as Hirschsprung's disease, anal atresia, spina bifida, and mental retardation, may hamper toilet training. Communication may be an obstacle, particularity among children with mental handicaps. When a child has impaired communication skills, determining the child's readiness to toilet train is more difficult. Azrin and Foxx's toilet training method was first tested in severely retarded adults and after proving successful, was adapted to children.³ Several researchers have hypothesized that toilet training will be less successful among children with delayed cognitive development; however, this association has not been consistently shown. Schum et al. found that cognitive development was not related to success of toilet training; however, children attending a program for the developmentally delayed were excluded from the cohort.¹⁸

Also, children with behavioral and developmental problems such as autism³³ or pervasive developmental disorder³⁴ may experience difficulty mastering toileting. Toilet training children with behavioral and developmental disorders is poorly researched and recommendations are not evidence based.

Previous attempts. Regression is a common component of toilet training and it is important for the parents not to appear anxious or disappointed and reflect this anxiety onto the child.¹⁶ If a child's toilet training regresses, the general advice is to abort toilet training and begin again in three months. This may remove barriers in the parent-child power struggle. Also, toilet training should not be initiated during a stressful time of a child's life, such as birth of a sibling, moving, or parental divorce.

Adverse Outcomes During Toilet Training

While the majority of children are toilet trained without incident, approximately 2–3 percent experience an adverse outcome. Five common problems involving elimination behaviors encountered during the toilet training period are enuresis, encopresis, stool toileting refusal, stool withholding, and hiding while defecating.³⁵ A sixth potential problem may be psychological consequences; however, there are no studies that investigate this.

Enuresis. Initially enuresis simply meant wetting and nocturnal enuresis was bedwetting. Each were thought to be psychiatric conditions and as such definitions were created in the Diagnostic and Statistical Manual. The Diagnostic and Statistical Manual (DSM) IV-TR defines enuresis as

1)

the repeated voiding of urine into bed or clothes (whether involuntary or intentional);

2)

the behavior manifests twice a week for at least 3 consecutive months or there is the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning;

3)

the chronological age is at least 5 years (or the equivalent developmental level); and

4)

the behavior is not due exclusively to the direct physiological effect of a substance (e.g., diuretics) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder).³⁶

New theories developed regarding the pathophysiology of nocturnal enuresis which included the presence of nocturnal polyuria versus uninhibited bladder contractions. Physicians then considered two pathological conditions involving wetting which included enuresis meaning day and night wetting, or nocturnal enuresis which was simply night wetting. Most of the current literature is written reflecting this. Enuresis is further divided into primary or secondary enuresis. Primary enuresis occurs when a child has not achieved urinary continence by 5 years of age. Secondary enuresis occurs when a child who has achieved bladder control regresses to urinary incontinence. The International Children's Continence Society is considering new definitions to better define these terms and improve consistency in publications however in writing this review we rely on older terminology which is potentially flawed. There is also literature that suggests that some children thought to suffer from simple nocturnal enuresis may in fact have daytime symptoms which have not been identified. It is possible that toilet training methods may impact this complicated and not well understood pathophysiologic condition.³⁷

Permissive and coercive toilet training methods have been associated with the development of enuresis in the literature.^{8 30} There are a variety of treatment options for enuresis, including behavioral, physical, and pharmacological interventions. ^{38 39}

Encopresis. Encopresis was also initially thought to be psychological and as such was given a DSM diagnosis. To be diagnosed with encopresis, a child must meet the following DSM IV-TR criteria:

1)

repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional;

2)

at least one such event a month for at least 3 months;

3)

chronological age is at least 4 years (or equivalent developmental level);

4)

behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation (http://www​.psychiatryonline​.com/content.aspx?aID=8096).

As with enuresis there are likely many factors which lead to encopresis and toilet training may be a component. Encopresis can also exist as a primary or secondary condition. Fishman et al. examined encopretic children and found that interrupted toilet training and punishment were associated with primary encopresis rather than secondary encopresis (50 percent versus 23 percent and 52 percent versus 26 percent respectively).⁴⁰ Encopresis can occur with or without constipation and overflow incontinence. Encopresis with constipation and overflow incontinence is characterized by the passing of loose stool that may include leakage varying in frequency, and it is most likely to occur during the day. Encopresis without constipation and overflow incontinence is sometimes associated with oppositional defiant disorder and conduct disorder (http://www.psychiatryonline.com/content.aspx?aID=8096 ).³⁶

Stool toileting refusal (STR). There are conflicting beliefs regarding whether children master bowel control prior to or simultaneously with bladder control.^{8 41} STR occurs when the child is trained to urinate in the toilet but refuses to defecate in the toilet for a period of at least 1 month. In a study conducted in a single suburban pediatric practice, researchers reported that 20 percent of children suffered from STR.⁴¹ There was a significant association between STR and training at a later age, having younger siblings, and the parents' inability to set limits.⁴¹ In addition, children with STR are more likely to withhold stool and develop primary encopresis.^{41 42} In a recent study, children who resolve STR are not at a higher risk for developing secondary encopresis.⁴¹ In a case-control study that examined whether children with behavioral problems were more likely to exhibit STR, Blum et al. found that oppositional and noncompliant behaviors were not associated with STR. They found that children with STR tended to be constipated and have painful bowel movements and recommended dietary changes or stool softening medications in the treatment of STR. In general, many parents do not perceive STR to be problematic and believe that it frequently resolves on its own.^{41 43}

There has been one RCT that examined an intervention to prevent STR.⁴⁴ Taubman et al. enrolled children in an RCT between the ages of 17–19 months of age. Children randomized to the treatment group received a three-prong intervention consisting of: 1) child-oriented toilet training guidelines, 2) parents only use positive words when referring to feces; and, 3) prior to toilet training, parents praise their child for defecating in their diaper. Children randomized to the control group received the same toilet training guidelines as the intervention group. While there was no difference in the incidence of STR between groups, the duration of STR and time to complete toilet training were significantly less among children in the intervention group.

Stool withholding. Stool withholding refers to any physical maneuvers a child may perform in an effort to avoid defecating.¹⁴ These acts include doing a “potty dance,” running, or crossing one's legs. Stool withholding can result in constipation because it often involves contracting the perineal muscles while the bladder and rectum are constricting.

Of 29 parents who sought medical intervention for STR, 23 cited “severe stool withholding” as the reason for requesting an intervention.⁴¹ The most common intervention was to return the child to diapers. Stool withholding may be further complicated if parents misinterpret stool withholding behavior as an indication that the child is not able to have a bowel movement.⁴¹

Hiding to defecate. Some children will hide from adults while defecating. This phenomenon can begin either prior to toilet training or after toilet training has commenced. Some children who hide while defecating are able to control when and where they will defecate and chose not to utilize the toilet.

This behavior is not well researched. In a cross-sectional study, Schonwald et al. (2004) found that 74 percent of children who had difficulties toilet training hid to defecate. Stool withholding is associated with hiding while defecating.⁴⁵ Taubman et al. compared children who hid to those that did not and found that children who hid to stool were more likely to exhibit stool toileting refusal, stool withholding, constipation behaviors, and toilet training completion at a later age.⁴⁶ The median age for the onset of hiding to stool was 22 months. While the authors were unable to determine why children hid while defecating, they hypothesized that this behavior may be in response to embarrassment, fear, or not having observed adults defecating, thus assuming it is a private behavior.