He just won’t poop
And not only that, the process of toilet learning occurs right at the age when toddlers look around them and notice gender differences. This is more striking when there is a little sister co-bathing or when parents go naked with the child present. And the little boys can’t help but see that half the population has lost their precious penis. Where did it go? No wonder they hang onto it. At 3-4 years of age, children do not understand about possible and impossible transformations. The disappearing turd certainly suggests its terrible fate.
Understanding which of the factors just described are at work is key to resolving stool refusal. The first rule of thumb is to assume that constipation was either a contributing factor or has occurred secondarily, and to aggressively give laxatives aiming for at least two inevitable stools per day. It is important not to have any more painful stools, and it is also easier to retrain a more common occurrence. I use MiraLax powder, usually 1-2 tbsp, dissolved and allowed to sit for 10 minutes in any desirable drink, which is then given at bedtime. Inform the parent that the dire warnings on the label about chronic use do not apply to their child. Continue the laxative until stooling in the toilet is completely without a struggle.
For the other causes, taking a regular history of daily functioning – such as mealtimes, bedtime, separations, sibling aggression, or regression – will usually reveal the dynamics, whether they are control issues, sibling jealousy, fear of the toilet or of school, or general attention-seeking. Translating the hypothesized dynamic to the parents is terribly important to acknowledge the meaning the child and often the family have given this behavior.
In the case of fear of falling in, using a potty chair firmly planted on the ground, and then progressive desensitization, practicing sitting while clothed, reading stories about toileting, and maybe a toilet scrapbook will gradually work as long as the child is not pressured.
To reassure about nurturance, instituting "Special Time" will help with sibling jealousy. This is also crucial when stool refusal is occurring with attention-seeking as the cause. I also recommend encouraging "infantilizing" during Special Time. This might mean offering a pacifier, feeding the child with a spoon or bottle, holding him or her in loving arms, and talking to them in baby talk. These instructions often meet with shock, especially from the parents who need them the most, as they directly confront their fear that this child will never grow up! It is extremely powerful for a parent to show, as well as tell, their child that "You will be my baby forever." All children have a strong drive to grow up, but some need this reassurance that growing up does not have to mean losing the safety and nurturing they associate with being an infant.
When power struggles appear to be the problem, it is best to put the child back in diapers all day while the parents work on a more appropriate balance between control and nurturance. Panties are a privilege to be earned. Using cloth diapers can make this step more effective as they are less comfortable when soiled. Be aware that the child is likely to revert in urinating as well once in diapers, but this does not require any different management. The parent and any other caregivers must show no emotion when the child soils or wets the diaper, but neither should they be in a hurry to change the child, instead postponing this attention for at least a few minutes. When they do clean up, it should be done silently and with neutral affect. This process helps remove any secondary gain that stool refusal was providing.
To address the child’s opposition, more work may be needed. The first step is usually reducing the number of demands the parent gives the child each day, but following through on each command by physically moving the child to do the task after only "one request." If parents are interfering in each other’s management of the child’s behavior, this should be corrected as well because the toileting dysfunction may be a reaction to tension in this dynamic.
Given that boys, in particular, may have the penis anxiety described above, I always reassure them with my "Penis Talk" that "boys are made with a penis and girls with a vagina. When you get big like daddy, you will have a big penis, too. Your penis cannot fall off, and no one can ever take it away."
