Parents find it difficult to change the behavior of children who have become dependent on, and will only poop and/pee in a diaper or pull-up. Treatment of these children occurs in three different phases each of which requires the effective use of incentives (pages 120-122) and star charts (131-133) as shown in my book:
Phase 1. Teach them to poop/pee in the bathroom while wearing a diaper or pull-up.
Phase 2. Teach them to poop/pee sitting on the toilet while wearing a diaper or pull-up.
Phase 3. Teach them to poop/pee sitting on the toilet without a diaper or pull-up.
The time it takes to successfully complete each of these steps varies with the age of the child, their level of anxiety about pooping without a diaper or pull-up and about pooping in the toilet. Parental patience and a willingness use "carrots" rather than "sticks" are essential.
The email below was sent to me by a real mom following a telephone consultation regarding her 6 year old son who would only poop in a pull-up.
Hi Dr. Tom,
I wanted to give you a further update on Kyle’s progress. Just 7 weeks after starting the strategies you and your book helped us design, Kyle is pooping on the potty every day! This is a child who could barely tolerate a brief sit on the toilet for over three years! I am AMAZED by how far we have come. As I reflect on what really made things work for us, four points come to mind.
1) Book and Phone Consultation. I want to tell you that I literally cried when I read your book. I was ashamed that my six year old could not poop on the toilet. The combination of reading stories from people struggling as we were, and thinking that your strategies might work for us was powerful. But I had reached a place of exasperation, confusion, and fear of doing the wrong thing. I still was not sure exactly how to proceed.
When I discovered that I could purchase a phone consultation through your website, I decided to give it a try. How thankful I am that I did! It certainly shows that you have been working with kids like Kyle for 30 years. You knew things about Kyle that even I didn't. Your understanding, guidance and support were invaluable. Perhaps most importantly, you gave me the insight and encouragement I needed to be patient. Luckily for us Kyle has made tremendous progress quickly, but I got off the phone feeling that even if it took many months that would be OK. We just needed to take baby steps in the right direction. It is normal for these kids to progress in such a fashion.
2) Chart Power. As you mentioned to me, there is a good reason why the chapter on positive motivation is the longest in "The Ins and Outs of Poop". Finding the right motivation for your child is crucial. I had tried charts before, but not designed in the way you describe. Several small steps, most of which I knew he could either do already or that would be easy for him, was key. He was still resistant, but that is where the abundant stickers and immediate reward came in. These were more powerful than I could have imagined. Seeing the beautiful sticker waiting to go on the chart in the moment after his effort meant so much to Kyle. He got over the hump of his reflexive resistance to all things potty! Once that happened and he started to focus on the extra video game time he would earn when his chart was filled, he willingly did his push practice every day.
3) Miralax. When allowed his pull-up, Kyle would poop every day or two. He didn't complain of painful BMs even when I asked him directly if discomfort was a problem. When I asked my pediatrician about a stool softener, she saw no need due to his regularity. You assured me that kids like Kyle need Miralax. Were you ever right! I started at a low dose and slowly increased as you suggested. It took longer than I had anticipated, but we finally got Kyle's poop to the right place on the "stool chart". What a difference this made for Kyle. Even though he could not verbalize his discomfort before he started Miralax, he sure could talk about how much easier it was to push the poop out once we had the Miralax on-board. I am convinced that he would not be pooping on the potty today without it.
4) Chart Power II. After about 4 weeks Kyle was much more comfortable sitting and practicing pushing on the toilet. His poop was much softer, and he reported easier pooping. He had even gotten a little bit of poop into the potty on a couple of occasions :). But he did not want to "push practice" when he really had the urge to poop. In those instances he was still using a pull-up. I tried to wait, encourage and reason, but to no avail.
Then it dawned on me - we need another chart! I designed a “Kyle's Good Pushing When He has to Poop" chart. It had to be formatted a bit differently than our "Push Practice" chart, but utilized the same principles. I made lots of small steps, most of which he was doing already. We used more beautiful stickers. And because what I was asking him to do was so tough and important, I made the reward more enticing - cash for toys. He still resisted at first, but one day, when I had that chart (already primed with a few stickers!) on the bathroom floor waiting for him, he gave in to my suggestion to "just try". At first he wanted to finish in the pull-up which I said would be no problem. More quickly than I expected, he didn't need the pull-up at all. Kyle was pooping on the potty!!!
Of course, Kyle is still at a tender place. We still have a lot of Miralax, laxative/stool records, and sticker charts in our future. But Kyle has achieved so much that eluded us for so long. You changed our lives Dr. Tom, and we can't say "Thank You" enough!