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Toileting relapses may require a few tricks: it may take just bribery or 'special time' or chocolate pudding painting or the 'penis talk.'.

WASHINGTON -- It's not uncommon for children to go through a relapse period with toilet training, and the trick to management may just be for everyone to lighten up, according to one expert speaking at a meeting sponsored by the American Academy of Pediatrics.

If a relapse does occur, "my advice is to relax, put them back in diapers, and wait," said Dr. Barbara J. Howard, a pediatrician at Johns Hopkins University, Baltimore. Be sure to consider urinary tract infections and diarrhea.

During periods of relapse, encourage parents to respond to accidents very matter-of-factly, rather than reacting negatively.

Sometimes all it may take is a little bribery--stickers, food rewards, or anything else that motivates the child. "M&M's work and here's how you do it. You get one for sitting, two for peeing, and three for pooping," said Dr. Howard.

The secret to this trick is that there is a reward for sitting. "It's not that these kids don't want to go to the bathroom, it's that they don't want to be bothered to sit down," she said.

This is especially true for children with attention-deficit hyperactivity disorder. "Many of the toileting problems that you're going to see--even in young children--are children who are too active to be bothered with this whole toileting thing."

Overlearning is another approach that can be very useful for toileting relapses, if somewhat tedious for parents. First, have the parents break the process of using the toilet into small steps. Following every accident, they should practice these steps 1020 times with the child and offer praise for each successful step. It may be helpful to demonstrate the steps first with a doll.

However, if toileting relapses have become a control issue or look like they started out as a control issue, "you have to deal with that control issue first," said Dr. Howard. It's more important to get general control over the child first, even if that means keeping her in diapers.

Relapses can arise from overcontrol situations--parents who never let the child do anything for himself--or undercontrol situations--parents who make no attempt to manage their child.

The first step with either case is to disregard toileting and establish reasonable limits, including limits on the child's aggression and intrusiveness. Dr. Howard advises parents of undercontrolled or intrusive children to follow one simple rule: "If [a child's behavior] feels obnoxious, stop it."

Sibling rivalry also can be a factor either because of stress, jealousy, or the desire to mimic the infant. In fact, roughly half of toilet-trained young children regress in their training with the birth of a younger sibling, said Dr. Howard.

Parents also may treat the older sibling differently, putting pressure on the child to grow up--increased focus on toilet training, purchasing a "big kid" bed, etc. This puts a lot of stress on the older child, who may already be concerned about being displaced by a new baby.

The key is "reassuring the child that they're always your baby and allowing them to do all kinds of baby things, especially during special time," said Dr. Howard.

Special time is an uninterrupted period of 10-15 minutes that is set aside every day specifically for the parent to spend with the child doing an interactive activity that the child picks out. Parents should give this time a special name--such as fun time, or Tommy's time. The parent picks and ends the time.

Special time works equally well with overcontrol and undercontrol relationships, said Dr. Howard. With overcontrolling parents, the value of special time is that the child gets to pick out and control the activity. Special time with a fun activity also helps undercontrolling parents feel better about setting limits.

Issues of modesty can often come into play with toileting problems because children connect toileting with sexuality. When a child presents with toileting issues, ask about nudity and modesty in the family. If it seems like there may be a connection, ask the family to cover up for a few months.

Sometimes children develop problems with toileting because one or both of the parents have had difficulty dealing with the mess associated with feces, making the child overly sensitive. "These children often toilet train beautifully for urine," said Dr. Howard, but when it comes time for a bowel movement the child requests and is given a diaper.

In these situations, Dr. Howard prescribes messy play for parents and children--such as chocolate pudding painting. By seeing the parents relax about this messy play, the child begins to relax about toilet training.

It's also critical to establish regular stool patterns, which may require the use of laxatives. Dr. Howard uses MiraLax (polyethylene glycol 3350, NF powder for solution) off-label because "you can dose it exactly right and if you let it sit for 15 minutes in a drink before the child takes it, they can't detect it."

Aim for two to three soft bowel movements per day during the period that you are working on control issues (roughly 68 weeks). "You can't toilet train a constipated kid very well," said Dr. Howard.

It's important to avoid a situation in which the child withholds stool out of a control issue and when the stool is finally passed it is painful and possibly even tears the rectum. This can induce a vicious cycle because the child will begin to fear the pain that has become associated with a bowel movement.

Once the control issues have been tackled and the child is having regular soft bowel movements, then it's time to practice sitting on the potty and to start with a reward system.

"The biggest incentive that children have to toilet train is often 'big boy' or 'big girl' underpants with some fancy action figures on them," said Dr. Howard. A child should not be allowed to have "big kid" underpants until he of she can go for at least at week without an accident.

For really resistant children--for whom nothing else has worked, including a period in diapers with no toileting pressure--room restriction may be in order. First be sure that control issues have been effectively dealt with and that the child is having a regular stool pattern. Then the parent should explain the following plan to the child.

Every day, 30 minutes prior to the child's regular bowel movement, the parent should put the child in underpants only (or the child can be completely naked) and restrict the child to one room of the house. The child is allowed to play in the room but no television or other electronics are allowed. The parent should tell the child that he can't leave the room unless he has "pooped in the potty."

"The first day, they may not go, but the second day, they are very likely to go potty," said Dr. Howard. If the child does not have a bowel movement on the potty, she cannot go out to play. If the child does have a bowel movement on the potty chair, she can then go out to play.

Typically this process takes about 4 days. "Once the child has given up this issue and has pooped in the potty, they don't want to talk about it any more. They don't want more rewards. They don't want to call grandma. They want to be done with it," said Dr. Howard. It's very important for the parents not to celebrate but to be as matter-of-fact as possible.

If the problem has been with urination rather than defecation, have the parent use "timed peeing."

"This is good for the kids who never quite make it back into the house," said Dr. Howard.

Have parents push fluids during this period. Every hour and a half, the parent should call the child in to urinate. If the child comes willingly, is dry, and attempts urination, he can go back out to play. If the child refuses to come in, is wet, of is uncooperative, he is grounded for the test of the day.

When toileting relapses occur, it may also be necessary to address toileting fears that the child might have. "Traumatic toileting fears usually happen because either the toilet seat fell down on his penis ... or they fell in," said Dr. Howard.

Automatic-flush toilets also can cause fear in children who are toilet training because children are too small to turn off the sensor. (One trick here is for moms to keep sticky notes in their handbags and to cover up the sensor before the child sits on the toilet.)

These phobias are managed like all others, with desensitization and relaxation. One idea is to make a "toilet scrapbook" with pictures from home magazines, while doing something relaxing. Dr. Howard recommends making the scrapbook while the child enjoys a lollipop because sucrose stimulates endogenous endorphins and has an inherent relaxation response associated with it.

Taking toilet tours of various bathrooms is another option. After they get used to visiting toilets, they should get used to sitting on the toilet in their clothes, and so on. This process usually takes about 6 weeks.

The key age group for this kind of problem is 3-5 years. If a child is older and has a sudden fear of the toilet, don't forget to rule out sexual misuse.

With nontraumatic toilet fears, there is no one incident to point to that scared the child. The first step with these kinds of fears is also to rule out sexual misuse.

Nontraumatic toilet fears tend to occur around the age of 3 years. "Three-year-olds don't get it that boys can't turn into girls and vice versa. The boys look around and they see that half of the population doesn't have one and they decide that it can come off," said Dr. Howard. Boys don't tell their parents about this fear, though, leaving the parents frustrated.

Dr. Howard recommends that parents give the "penis talk," which goes something like this: "Boys are made with penises and girls are made with vaginas. [For boys] When you get big like daddy, your penis will be big too! You get to keep your penis forever; nothing can ever take it away. [For girls] You never had a penis; you will have a vagina forever."


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Title Annotation:Behavioral Pediatrics
Author:Wachter, Kerri
Publication:Pediatric News
Geographic Code:1USA
Date:Jul 1, 2006
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