My pre-schooler insists on using a nappy

Q Our son is four since May and will use the toilet to urinate, no problem. However, he point blank refuses to use the toilet for number twos and insists on a nappy. I have tried to get him to use the toilet and he will sit on it sometimes but refuses to do anything.

To give you some background– he has a younger brother and sister and his father works abroad and is home for only a few days each month. So most of the time I am a lone parent.

My parents visit and my mother thinks perhaps he is jealous of his siblings as he will also occasionally refuse to dress himself or do other simple tasks. Any advice would be welcome as he has just returned to playschool and the expectation is for him to be toilet trained.

A Despite what they might say in parenting books, the road to being fully toilet trained is often marked by many setbacks. Though people tend not to talk about it, many children continue to have accidents or problems at preschools and even after school starts.

Learning to urinate in the toilet is generally much easier for children as it is something they tend to have direct control over and they can try on demand. However, bowel movements can prove more difficult for children, as this requires children to be relaxed and to be able to “let go”.

Over-trying or forcing a bowel movement can be counterproductive, particularly if a child is constipated. Many children have an experience of passing a bowel movement as being painful and then “hold on” and avoid it the next time.

This can lead to further constipation and further avoidance – in serious situations the child can be become impacted which results in them losing control over their bowel movements resulting in frequent accidents.

If you think your son is constipated or you have any concerns like this, you should visit your public health nurse or GP to rule out any physical cause and to gain treatment as appropriate.
Adopt a gradual approach
In helping him learn how to use the toilet, a gradual step-by-step approach can work best. First, take time to observe your son's current awareness and routine around his bowel movements.

Is there a particular time of day when he is likely to go? Does he have an awareness of when he does it or does he have a particular ritual around it (eg where he goes)?

Once you have a sense of what he does already, then you can encourage him to make the next step. For example, if he hides when he does it, really encourage him to tell you or if he only tells you after the event, try to teach him how to notice the signs when he is about to go (perhaps by reading a children’s book on getting to the toilet quickly).

If you notice he needs the comfort or association of using the nappy before he can go, think how can you reproduce these positive associations when sitting on the toilet. One mother I worked with made a breakthrough when she let her child overcome his fear of the toilet by letting him sit the first few times in his nappy before gradually weaning him off this.

Attention-seeking behaviour
You mention in your question, that you wonder if your son's behaviour is as a result of being jealous of his brother and sister.

This can be the case especially if your son has used the toilet appropriately before and might now have regressed as a means of getting your attention. In addressing this, the key is to try to respond as neutrally as possible when he has an accident (see below) and instead ensure he gets positive attention whenever he tries to use the toilet.

Set up a special rewarding routine whereby he gets your special attention if he sits on the toilet. For example, you might pick a 10-minute period during the morning (that coincides with the time when he most likely wants to go) when you will be with him as he sits on the toilet and read books with him or allow him to play with a favourite toy or game. For example, blowing bubbles can be an excellent choice as children love this game and the action of blowing bubbles can encourage relaxation and letting go in the bowels.

Setting aside this time as a busy mum with two other young children can be hard, but perhaps you could integrate it into the family routine (eg during naptime or all four of you together in the bathroom for playtime) or maybe you could ask another family member to visit at a regular time each day.

Using a star chart can provide extra motivation whereby your son gains a star for sitting on the toilet and a special big star or extra reward when he has a bowel movement.

Dealing with accidents
When your son has an accident, it is important to respond positively. Expressing frustration or giving out to him might make him more likely to "hold on" again and be reluctant to tell you when it happens.

Instead, try to be positive and say something like, “Great you have told me, now next time let’s see if we can get to the toilet before.” You can consider employing a mild consequence whereby he has to help clean himself up (eg he has to stay in the bathroom until he is clean and dressed). This encourages him to take responsibility for his behaviour and might motivate him to change. The key is to implement this consequence non-punitively and as positively and calmly as possible.

Work with the preschool
The fact that he is attending preschool
can feel like a pressure to get him toilet trained. However, pressure is often unhelpful, when patience is required.

You might be able to negotiate with the teacher that he will go to preschool in pull- ups and that you will be available nearby for major accidents. Even children late to be toilet trained often get quickly into the habit of staying clean in preschool and waiting until they are home. Taking the pressure off at preschool, gives you time to work patiently at toilet training at your son’s pace at home.

Dr John Sharry is a social worker, psychotherapist and director of the Parents Plus charity. His new book, Parenting Teenagers, (€7.99) is out now. See solutiontalk.ie