Family doctor

 Most parents begin toilet training their children at about the age of 2 - 2 1/2 years, and by 4 years of age more than 90% of children are reliably clean and dry during the day. It is important to state at the outset that night-time dryness is achieved as the result of neurological development and maturation, not as the result of daytime toilet training, and only about 80% of children will be reliably dry at night by the age of 4, as compared with the daytime figure.

 SOILING

 When should soiling (the medical term is encopresis) be regarded as a problem that needs to be dealt with, rather than as a developmentally normal behaviour? The answer to this question depends partly on how often the soiling occurs, and how much is passed, but so-called "accidents" (other than skid-marks) should be a rare event after the age of 4. If a child is still occasionally passing substantial amounts into their pants, or frequently passing small amounts over the age of 4, then it is a problem which needs to be addressed. The approach to be taken will depend on the particular type of soiling problem.

 Late developers

 Some children are generally slower in all aspects of their development, and toilet training is just another example of this. With these children there is no physical problem causing the soiling, and no anxiety about using the toilet. They are quite capable of passing a motion into the toilet, and are happy to do so on request, but sometimes they just don't make it in time. For these children the term "accident" seems to be an appropriate description for the nature of the incidents.

 These children are following the same developmental path as their age-mates, but at a slower rate. Because of their general neurological and intellectual immaturity, it just takes longer for toilet training to be achieved. Treatment involves the same methods used in normal toilet training, but with a little more patience and perseverance than usual, and greater emphasis on extrinsic motivators such as stickers or sweets for maintaining clean pants.

 Toilet refusers

 This group of soilers are developmentally normal, but for some reason have a strong aversion to using the toilet. They prefer to pass their motions into their pants, often in a special location such as behind a couch or door. Some don't like to soil their pants, and will ask for a nappy to be put on. Some will wait until their bedtime nappy is put on before passing their motion. The reason for their reluctance to use the toilet is usually unclear, but is probably anxiety-based and may be related to an earlier incident of painful defecation following constipation. These children are usually not at all reluctant to use the toilet for urination.

 Treatment for this group is difficult, because any attempt to put pressure on them to use the toilet is likely to result in a stand-off. They may refuse to go, sometimes for days, which results in constipation with all the extra drama and unpleasantness which this brings, together with the risk of a painful motion which then makes the original problem worse.

 One method is to use a graduated approach to the final goal of using the toilet appropriately. The first step is to allow the child to pass a motion as they usually do, but (a) only into a nappy, and (b) only in the toilet area. These requirements are the beginning of "shaping up" more appropriate toileting behaviour. The next step is for the child to defecate into a nappy while sitting on the toilet, then while sitting on the toilet with the nappy held a little distance away from their bottom. Finally, everyone agrees that the nappy is just getting in the way and is no longer needed.

 The use of rewards as an incentive on their own tends to be ineffective with this group, because their reluctance to use the toilet is so great, but it can be helpful to use rewards, eg special sweets or stickers, as an adjunct to the above programme.

 A more direct form of intervention is to use either a laxative or a suppository to take away the child's control over the retention and timing of the motion. This avoids the problem of constipation, and makes it more likely that the child will comply with your direction to pass the motion into the toilet because they have less control over the process.

 Whichever method is used, once there have been a few successes the problem usually disappears. Even without any kind of intervention, in my experience it is very unlikely that the behaviour will persist past the age of 5.

 School-age soilers

 This third group, who continue soiling into their primary school years, is quite unlike the first two groups because there is - or is likely to be - a genuine physical reason for the continued soiling.

 These children (usually boys) have never been reliably clean for more than a few weeks or perhaps a few months at a time. They are most unlikely to pass a full motion into their pants, and have no anxiety about using the toilet, but will soil their pants most days to a level which is immediately apparent to others nearby. Although the smell is very noticeable to others, these children seem not to be aware of it, or to be worried by the physical discomfort of dirty pants.

 Most of this group suffer from chronic constipation, which leads to the forming of a hard faecal mass in the colon, with overflow of softer material around it. The constant stretching of the colon with packed faeces actually causes it to become distended, with some loss of control and sensation, which makes it difficult to establish a normal toileting routine. These children may need a brief hospital stay to clear their bowels, and take the first steps towards a normal toileting pattern with the help of appropriate diet and medication, but it takes some months for the colon to regain its normal shape and function.

 The more puzzling and difficult children to deal with are those with no apparent physical problem, and who do not suffer from constipation, but who pass small amounts into their pants most days. It is easy to see this kind of soiling as having a psychological cause, but my impression has always been that there must be some kind of subtle physical factor which affects bowel sensation and/or control in these children because of the chronic and persistent nature of their soiling, and in the absence of any obvious psychological cause.

 Treatment for both these sub-groups is based on the simple principle that there can be no soiling if the bowel is empty. The emphasis is on producing regular and predictable evacuation of the bowel, and involves:

•   an appropriate high-fibre diet
• appropriate medication if necessary
• being aware of and being ready for the times when the child is more likely to pass a
• motion
• keeping a record of when accidents occur, so that "danger times" can be highlighted
• encouraging sensitivity to any signals from the bowel that action may be imminent
• the use of a daily sticker chart for clean pants (with accumulated stickers being traded
• for negotiated rewards).

 The bowel's natural tendency to move after the intake of food is a great ally in the campaign against soiling, because it enables parents to predict when a motion is likely to occur and encourage the child to sit on the toilet at those times.

 Many practitioners use the "Sneaky Poo" story to represent soiling as an imaginary enemy who can be fought against and defeated. This story almost invariably interests children and motivates them to fight back against their soiling problem.

 Unfortunately, despite all efforts relapses are common, and final remission probably depends on physical maturity.

 Sudden onset of soiling after a long period of being reliably clean, with no evidence of illness, is likely to be due to psychological stress.

WETTING

 Problems with wetting are less common than soiling. The three main causes of daytime wetting ( known medically as enuresis) are:

•  developmental delay
• anxiety
• a physical problem with retention.

 Late developers

 As discussed above in the section on soiling, some children are simply slower to develop than others, and will continue to have wetting accidents through their fourth and fifth years, and sometimes into their first year at school, before becoming reliably dry. These children require regular toileting, and probably also the use of rewards dependent on having dry pants. With younger children (3- and 4-year-olds) use powerful immediate rewards such as a preferred sweet. With older children use stickers on a chart which can be accumulated and traded in for a treat.

 Anxiety

 It is well known that anxiety can lead to frequent urination, and with young children whose physical control is not completely established, anxiety can lead to wetting accidents. This type of situation is not common, because the anxiety needs to be considerable in order to cause wetting. For example, sudden onset of wetting after a long period of sustained dryness, and in the absence of illness, can be an indicator of abuse. Treatment involves identifying and removing the cause of stress.

 Incidents of night-time wetting after a sustained period of reliable dryness are also likely to be due to daytime stress or worry.

 Physical causes

 Children who continue to wet during the day past the age of 5, and in the absence of any identifiable source of stress, are likely to have a physical problem with the retention of urine. If a child continues to wet after appropriate medical assessment and treatment, they may respond to a variation of the "Sneaky Poo" programme directed at being dry rather than being clean, but once again any success with this programme tends to be temporary until the child reaches an appropriate level of physical maturity.

 Night-time wetting

 Night-time wetting has a different cause and is treated differently to daytime wetting. See

BEDWETTING ARTICLE.