6 months of potty training and total refusal

[HardySi]

I've searched around the site for answer to this, but as always there seem to be fairly unique circumstances. My daughter started potty training six months ago (at 3.5 years). Even well before she started potty training we were aware that she was holding in her poos. She's been on Lactulose for at least 18 months to soften her stools.

Over the past 6 months, she has never fully done a poo on the toilet. Naturally, if she looks like she is going, we take her straight there. Sometimes we've sat with her for over an hour whilst she is on the toilet, with no success. As soon as she is off and our backs are turned, she will let out a minimal amount in her knickers. Yesterday, we got through 10 pairs of knickers, all with soilings, but not full blown poo. We've tried bribery, regular toilet times during day, long reasoning...

With regards to wees, she is ok but rarely independently goes herself. If we do not take her more likely than not she will eventually wet herself.

My wife thinks there is not much we can do. But the fact remains we do not know how to deal with it. My daughter says she is scared that the poos will hurt if she let's them out. This is psychological, possibly a physscal problem. We are not equipped to deal with it, having no luck with GP of health visitor. I know there are worse things, but it's causing stress in our relationship and probably in ourughters life als.

Any advice gratefully received. I know it comes accross that I am newbie!

I think that the dose of lactulose isn't enough, I would get medical advice before increasing, so as to get the right dosage.

You are right in that your DD has a psychological barrier to pooing, this must have started while she was still in nappies, and had a very painful poo. I think that perhaps if the soiling you describe is soft, she may well have compacted poo higher up in the bowel, where the softer stuff leaks past the blockage. She may need something like Movicol to increase the motility of the bowel, the Dr will prescribe it. You can increase the fibre in her diet and give more water to drink to help. Wetting can be a problem with constipation, kids hold on in case they need to do a poo, and also the nerve signals can get a bit messed up. I think that holding on to a poo can be very difficult on Movicol, so you might get a few massively messy accidents, but at least they will be full packages rather than lots of smears. After a few of these, she may be less fearful of it hurting.

I think that this has gone past the stage of just constipation and is now encopresis (google it) I do urge you to read as much as you can and get your daughter referred to a specialist, after 18 months of getting nowhere this is causing problems for the whole family. Your DD will not respond to anything with an undercurrent of anxiety at home. I'm appalled at the lack of help from GP and HV.

Girlywhirly - Thanks ever so much for your detailed and insightful response; it's much appreciated. We are away but will take her to doc armed with this information which gives me more courage to insist that we get specialist help. And nice that dads are welcome on MN! :-)

Hello we are having the same problem with my youngest ds, i was putting it down to him being a boy!
I think the most important thing you can do is to just stay calm about it, don't tell her off, keep encouraging her to sit on the toilet, perhaps with a book or something to keep her occupied. I am a school nurse and have worked with older children with similar difficulties and movicol has been really helpful. Defo up the fibre too so brown bread and weetabix are current favourites in our household! Keeping hydrated so lots of water and ++++ fresh fruit & veg! I am not sure the gp can do much more than perhaps prescribing movicol but your hv should be able to do this and give you more advice and support... I would keep in mind that she is still only young and all children develop these skills at different stages, I am pretty sure many of her friends prob still have accidents and are scared of pooing in the toilet. The more she sees others using the toilet at home and nursery etc... might encourage her too. Good luck x

momma2lilboys - Sorry for the delayed response - holidaying with no proper internet access, which I guess should be welcomed. Thanks for your response and advice. Yes, the stuff on fibre is good and with no encouragement from me she downed 3 weetabix for b'fast yesterday. But I do feel that after 6 months of encouragement, books, bubble blowing on toilet, seeing others use toilet, there's been virtually no progress, which is why I feel the problem goes deeper than this. And even though I consider myself a calm and relaxed person, it's impossible to be so constantly for this length of time and with no longer-term plan or understanding of what is or may be going on, it is stressful. Off to the docs this week with some good advice and insight from here, so let you know how I get on.

I thought I would update. My wife has been to docs and seen health visitor without no success. Doc was new to the area so not up on what services were available. Said she would get back to us but never did. My wife was there on another matter and saw the best health visitor (she'd met before) and again, some general advice, but never came back as promised. Both times my wife was in tears, not for dramatic effect, but just because this is the point we are at. I have to say that after an hour on the net, I did receive a lovely reply from Dennis Neill at www.familytherapy.org.uk/ on encopresis as he has a very informative leaflet on his site. However, the view is that very difficult to get it considered an issue in a four year old. She's on Movicol, but the underlying problem remains and there has been no progress whatsoever despite all manner of approaches. What feedback we did get from doc was that Psychological services were severely cut back in our area (Herts) that that this would not be considered a priority. Ok, there are worse things, I acknowledge, but do we have to wait until she is older, the problem is even more entrenched and has created further issues before we get help?

Have you considered paying for private treatment, because this might be your only option. I am also surprised that none of the healthcare professionals have ruled out physical problems (anatomical) before deciding that this is purely a psychological problem. Has your DD ever been properly examined?

I don't know if this would work in the meantime. Go back to the beginning of potty training, buy a bigger potty if necessary as it's clear the toilet is scary. Drape a disposable nappy over the potty for her to sit on when she needs to poo, but cut a slit in it so that the poo will hopefully land in the potty, and if she has passed it with no pain hopefully will be encouraged to do it again because it didn't hurt. The nappy is there just to make her feel more secure, a bit like pooing in her knickers. She might only do a bit to begin with rather than the whole poo, but at least you have something to praise and reward her for as she is essentially doing it in the right place. Buy cheap value type nappies for this. When you get a good result you can restrict the rewards to poos in the potty only, and clean pants. You will have to be very positive about successes, and very neutral about failures. No telling off, or pleading or discussion; just change without comment, beyond "try on the potty next time" in a calm voice. Perhaps DD could take charge of putting her soiled pants in a bucket to soak, clean herself up with wipes etc.

There is another reason why I suggest a return to the potty, physiologically it is better for a child to poo in a squatting position as it empties the bowel more efficiently. This doesn't always happen sitting with legs dangling on the toilet, unless the child has a very high step which raises the knees higher than the hips.

I think you need to try as many avenues as possible before getting treatment, to convince the HCP's that nothing has worked. The above method has worked for DC who were afraid of pain when pooing, or that bits of their bodies would fall out, and so on.

Belated thanks for your response girlywhirly. I just wanted to respond when had some news. We've just finished 4 sessions with parenting coach, who has done some work in this area but not exactly the same. There was almost a placebo effect of DD responding (after complete meltdown) as she was aware that someone new was in the house and the situation was being discussed. After that there were some really great period during which she managed to poo on the toilet, once for several days in a row. She responded well to rewards and stickers in a book etc and really enjoyed her successes.

Both our kids were then really for a week with really bad virus and lots of vomiting. This took us straight back to square one, but we knew that she could do it, it was not painful or a fear of the toilet etc. last week was a bad one but the weekend was good, helped by the fact that I did not allow her to wear to wear trousers or knickers in the house. I would not have done this Previously, but did so because I knew she was capable and there were no physical impediments. But the periods of success are still outweighed by days like today when she will soil herself half a dozen times or more. For us, we are finding it more difficult because we know she is capable, but after nearly 10 months, it's tough. Doctor has said not a chance of being referred to CAMS because she is too young and more important things to be dealing with.

I am just posting for any further thoughts or inspiration. Parent counsellor could return but she's largely winging it and totally acknowledges that we are doing a great job and this is a very happy and 'normal' home. The only thing I can see from here is going to doc and insisting that get referred, given greater knowledge of situation that we now have, but of course that could take months.

Hardy, I'm glad to hear that you have got somewhere with your DD. It is interesting that she responded to the parenting coach, perhaps because she didn't want a stranger to think badly of her, and also because he/she was not (in DD's eyes) someone who could be defied. Because she is so emotionally attached to you as her parents, she feels she can do as she likes and revert to the previous pattern of soiling/emotional tugging at your heart etc because that is what she always did. It is a behaviour that has always succeeded before. I've known a girl of 3.6 who would wet herself if she was annoyed with her mum, standing right in front of her and announcing the fact as she was doing it with a grin, just to get her back!

Obviously during the sickness it was difficult for you all, but it's good to know that you did go back to some successes. I am wondering if the good days correspond to when she is happy and everything is rosy in her world; and that bad days are when she has been told off maybe, or the activities are not to her liking, or she isn't getting her own way. Could you find a pattern of soiling relating to behaviour?

Thank's for your response. Just now DD called to say she had done a poo in the toilet. But my wife said that she just really had a meltdown (my wife, not DD!) beforehand as she's so frustrated and fed-up with it it all (for reasons explained above), so DD then promptly complies and does one in the toilet.

I don't necessarily see a correlation as you describe with moods etc., but it's a good point and one we will try and track over coming days. She's a generally happy and smiling child and we are both pretty even with her and make sure that she does not get her way via the odd tantrum or dramatic slump face-down on floor with eyes shut. Maybe this is her release valve? I don't know, just a thought, because she herself is quite controlling and ordered (things have to be put away, DVDs in player label facing forward etc.). Your advice very useful, much appreciated and will be acted upon. Thanks!