Q. My grandson is 4 1/2 and still not potty trained as far as his bowels. He's in preschool, as well as before- and after-school care. He usually holds his bowels throughout the long, 12-hour day. We just can't seem to get him trained.
-- A Grandmother in Minneapolis
A. By 3 1/2 , most kids are potty trained. After that, "waiting until the child is ready" is no longer an appropriate option.
"Teaching at 4 1/2 is hard. It's like teaching a kid to ride a bike at 12 rather than at age 7," says Jan Faull, author of "Mommy I Have to Go Potty!" (Raefield-Roberts, 1996). "They've learned to accommodate to not using the toilet."
Parent to Parent will address this issue in two parts. This week: insight from experts. Next week: tips from parents. Neither column is a substitute for medical advice.
"A lot of kids don't like to go away from home, and it can be a difficult problem," says Faull, who finds that "busy lifestyles, disposable diapers that do their job too well, and multiple child-care providers coaching in different ways" can slow down the toilet-training process.
To figure out the training approach that best suits your child, it's important to pinpoint the reason for the delay, says Charles E. Schaefer, psychologist and co-author of "Toilet Training Without Tears" (Signet, 1997). He says three of the most common reasons are:
Constipation: The child holds back his bowels to avoid discomfort.
Fear: Some kids are afraid of tumbling into the toilet, and prefer the comfort of their diapers.
Immaturity: The child is distracted and too busy playing to be bothered with going to the bathroom.
"I spent many months thinking that if I could just find the key, we would get past this," says a mom from San Francisco who calls her initial approaches "all wrong." Constipation, along with an "I'm too busy" attitude, proved to be the links to her son's training difficulties.
First, physical and developmental complications need to be ruled out, says Schaefer, whose detailed toilet-training guide includes chapters on how to help resistant kids who are 3 1/2 to 5 and kids with delayed bowel control.
If constipation is the culprit, he says, the child may need:
Treatment with an enema or laxative for what Schaefer calls an "initial clean-out" of an impacted colon.
A modified diet high in fiber and liquids.
Two or three times scheduled daily for him to sit on the toilet and try to have a movement. Generally, toilet times should be 15 to 20 minutes after a meal.
Small incentives to keep the child motivated.
One 4-year-old boy, whose parents are also looking for help, appears to be in the "fear" category of reasons for delayed bowel training.
"He knows when he has to go and wanders off by himself and goes in his pants," his mom says. "We've caught him doing this and have set him on the toilet for 30 to 45 minutes with no luck, and five minutes later he goes in his pants. He has gone to preschool for two years now and has never gone in his pants there. He says he's scared."
First, tell the child he can ask for a diaper to use for his bowel movement, but he can use it in the bathroom only. Otherwise, no more diapers.
He advances to sitting on or near the toilet with his diaper on.
When he's comfortable with sitting on the toilet with his diaper on, pull or cut away part of the diaper so that some of his BM falls in the toilet. For any new approach to work, whether your child is constipated, afraid or too busy, everyone who cares for him needs to matter-of-factly follow the same steps, be aware of his normal schedule of bowel movements, and have plenty of patience, says Faull, a parenting educator in Seattle.
"I recommend that parents don't talk much about it," she says. "Make your expectations clear, but we don't want to hound them about it."
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