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!

Parents of children with functional constipation often report that their child will urinate in the toilet with no problem but will only defecate if they are wearing underwear or are in a diaper or Pull-up. Why is this? Understandably, parents think that if their child is relaxed enough to pee in the toilet he or she should also be relaxed enough to poop in the toilet. However, as I explain in the 2nd edition my book The Ins and Outs of Poop: A Guide to Treating Childhood Constipation, the fear that underlies functional constipation is related to relaxing the anal sphincter (not the urinary sphincter!) whenever a child consciously or subconsciously feels the need to poop. Most of the children who pee in the toilet but do not poop in the toilet are still actively withholding and frequently have poop "accidents" in their underwear or diapers (See Chapter 9). In my book I explain why withholding must be treated and stopped before the application of "successive approximation" behavioral strategies can enable these children to poop on the toilet without fear ( See Chapter 16).

Many children with encopresis will only poop in a diaper or a pull-up. The longer this continues the more their parents worry that it will become a habit.

Here is what one mom recently said to me:

"No need to worry about her developing a habit of standing to poop. She will sit to poop when she is ready. She must first unlearn the habit of withholding. This requires many, many experiences of having a medium to large bowel movement every day, that is softer than normal (e.g. applesauce or pudding consistency) and that does not hurt or cause her discomfort. Unlearning the habit of withholding is a very slow process. The length of time is different for each child, especially for 2 or 3 year olds. You cannot and should not rush her.

A parent of a child who will only poop with a diaper on recently wrote me the following, “My daughter poops in her diaper in the bathroom while standing or lying flat on the floor. But, if I ask her to even just try sitting on the toilet with her diaper on, she refuses. I have offered her prizes and she still says, No way! Help!”

Parents of children who will only poop in a diaper or pull-up often find that it’s a lot easier to get their child to go into the bathroom to poop in their diaper or pull-up than it is to get them to take the next step which is to simply “practice” sitting on the toilet with their diaper on. The sequence of steps necessary to reduce the subconscious fear that is preventing these children from sitting on the toilet is detailed in Chapter 16 of my book, “The Ins and Outs of Poop”.

For many children, sitting on the toilet with their diaper on (or off) is the scariest and, therefore, the most difficult thing for them to do. That’s why children resist so strongly and are often slow to respond to incentives.

Don’t give up. Be patient. Do not rush your child to sit on the toilet.

It can sometimes take months for a child to relax enough even just to try sitting on the toilet with a diaper on. And it can take months for this same child to then relax enough to just try sitting on the toilet with no diaper. While that may seem like a long time, remember that time, patience and understanding are the keys to eliminating fears, in children and adults.

Parents frequently ask me, generally in exhasperation: "Why do I always have to remind him to go into the bathroom and try to poop?" 

This question typically occurs sometime during Steps 3 and 4 of my 6 Step Treatment Program (as outlined in detail in my book), when a child is having daily bowel movements but, in many cases, only with parental reminders.

Parents generally think that, by now, their child must feel the urgency to poop, because when he does sit (and push), he almost always gets poop out. They worry that their child will become dependent on them and never learn to go to the bathroom on his own.

I tell them to be patient and not to worry.

I remind them that at this stage in treatment, their child’s rectum has not yet shrunk back to its normal size and, therefore, his ability to sense the need to poop is inconsistent, at best. The main goal at this point in treatment is for a child to have at least one large, very soft bowel movement every day, regardless of whether he does it on his own.

In the meantime, always offer a small reward for going to the bathroom without needing to be reminded. You might also ask him to tell you when is going to go try, and praise him for telling you. But try not to punish, scold, or express frustration when he does not remember.

Some children find it extremely difficult to poop or pee without a diaper or pull-up on. As mentioned in the previous posts on this topic (see list at the end of this post), wearing a diaper or pull-up helps them relax their poop and pee muscles, in part by assuring them that their poop and pee will not drop into the toilet.

Eliminating diaper or pull-up dependency is a two-step process which is described in further detail in my book:

The first step, counterintuitive but necessary, is to get your child to poop and/or pee while sitting comfortably on the toilet with his diaper on.

The second step involves cutting progressively larger holes in the diaper or pull-up, starting with slits so small that neither poop nor pee will drop into the toilet.  This process may sound strange and/or tedious, but I have used this technique for over 20 years and it really works!

The key to success is to proceed very, very slowly because most diaper dependent children will refuse to pee or poop if they perceive the hole in the diaper to be too big.  This can be avoided by asking your child at each step of the way if he or she is comfortable trying the larger hole. If not, stick with the smaller hole until your child is ready to try a slightly bigger one.

While for some children this process only lasts one or two weeks, it is also completely normal for this hole-cutting process to take months before the child is comfortable enough to let the poop drop into the toilet through the hole, and subsequently to allow the diaper or pull-up to be removed completely. Parents have found Chart #6 in Chapter 16 in my book to be helpful in guiding their children through this process successfully. And don't forget the use of incentives and visual sticker charts to reward each small shift in behavior!

Previous posts on this topic are located in the "Only Poops in a Diaper" category, see far right column or below:

Poops Only in a Diaper? Your Child Is Not Alone

Older Kids Who Still Wear Pull-Ups

Real Poop Story: A 6 Yr-Old Who Will Only Poop in Pull-Ups

Real Poop Story Cont'd: A 6 Yr-Old Who Will Only Poop in Pull-Ups