My five-year-old son has major problems going to the toilet

My son, who is just five, has been having major problems going to the toilet and in particular “holding on” to his number ones s and number twos so much so that I feel it is having a major impact on his life and wellbeing. There is nothing medically wrong with him, in that once he goes everything is normal but it’s the going that’s the issue.

He can go for hours without doing wees and a couple of days without doing number twos. He has a healthy diet and loves his food so again it’s not related to that. He has developed a habit of squeezing in so much that his body is rigid and he holds his hand up to his face and clicking his fingers as if to distract himself. This can go on for hours and he will do it when he is sitting or standing.

I try to sit him down and talk to him in case something in particular is bothering him. There has been a lot of change in the past few months such as having trouble settling into school in September and finding the yard hard.

I also I went back to work for three days a week and he is being looked after by a childminder for the first time ever. Also, he has a 2½-year-old brother who is very demanding and going through the terrible twos with a vengeance and this definitely upsets him.

I feel the problems have escalated in the past six months in particular and is now leading to accidents in his underwear. I will be honest and tell you that I am not good at coping with the “accidents” especially from a soon to be five year old! The accidents have never happened at school or with the childminder, just at home.

I would really appreciate your help and advice on this as I don’t know how to help my son and I feel it will lead to medical issues if it continues.

ANSWER

Ongoing toileting issues for children over five years are a very common, though not much talked about, problem. Unfortunately, lots of children get into habits of “holding” and avoiding using the toilet, mainly for bowel movements though sometimes for passing urine also.

In my clinical experience, the cause is almost never to do with emotional reactions to potentially stressful events like you describe in your question such as changes in child care, or jealousy about a new brother, etc (though lots of professionals often incorrectly propose this.)

While toileting problems can of course be emotionally stressful (not to mention messy) for both parent and child, stress is the result and not the cause of the problem.

Why children have toileting problems

Children can get into a habit of “holding” and avoiding the toilet for a variety of reasons. Sometimes, they have a memory of discomfort or pain making a bowel movement due to constipation, which means they subconsciously “hold on” to avoid repeating this painful experience.

Sometimes they have specific fear of using the toilet in certain places (eg school or home) or they have very “rigid” rituals of how they go to the toilet (always want to do it in nappy, etc).

Frequently, some young children are not yet fully toilet trained and thus are still learning good toilet habits. Once a child gets into a habit of “holding”, it can cause secondary problems such as constipation, which can lead to accidents. In the case of bowel movements, accidents are usually the result of severe constipation where the child has lost control of his bowels so that the faeces leak out – at this point he can longer manage when he goes.

In helping your son, the first step is to appreciate that the problem is not his fault and to be very understanding in how you respond. The second step to address the underlying constipation and then to work at positively encouraging good toilet habits. This can take a lot of patience over an extended period.

Treating constipation

Dr Steven Hodges, a paediatric urologist, believes that undiagnosed and untreated constipation is the number one cause of ongoing toileting accidents in children old enough to be fully toilet trained (eg aged five and onwards). In his book It's no accident and on his excellent parents website bedwettingandaccidents.com, he describes how you can assess and treat constipation, which usually requires the systematic use of laxatives over an extended period of time (usually several months).

Consult with your public health nurse or GP about having your son reviewed and treated. Some of the children's hospitals in Ireland run specialist toileting clinics that might be able to help. There is also an excellent UK based charity to help children with bladder and bowel problems - www.eric.org.uk- who have great information and a helpline.

Helping your son get into a good habits

In parallel to addressing constipation, it is also important to encourage your son to have good toilet habits. In your question, you say he does not “hold on” in school, does that mean that he sometimes uses the toilet in a normal way there? Would it be worth observing or finding out what happens in these successful times? When he uses the toilet normally at home, what specifically happens then? How does he do this? This might give you some clues as to how to help him.

In a nutshell, the goal is to increase his comfort when he goes by helping him relax. Set up a good routine about using the toilet, perhaps having a fixed time in the morning after breakfast when there is no pressure. Make it a fun relaxed time by maybe reading on the toilet together or even playing music, etc. Help him have a relaxed posture by using a footstool for his feet so he is in a relaxed squat position.

Think what would make the experience of being in the toilet fun and relaxing. I often recommend that parents keep special bubbles in the toilet and you can blow one or two together when she sits down. Bubbles can distract a child from any discomfort and the motion of blowing can even help them relax and let go in the toilet.

There are also some good books such as Bedwetting and Accidents Aren't your Fault by Steve Hodges which you can read with your son to help can him understand what you need to sort the problem out together.

Dr John Sharry is a social worker and psychotherapist and co-developer of the Parents Plus Programmes. See solutiontalk.ie for details of his books and courses