A four-year-old refuses to surrender pull-ups

Q. Despite trying all the usual management techniques for the past year, a developmentally normal 4-year-old continues to avoid urinating or defecating anywhere except in a pull-up. Her parents tell her she must use underwear only, but she holds stool and urine for 15 hours! The parents eventually become concerned and put the pull-up on before bed, at which time the child goes immediately. The child understands sticker charts and so on, but refuses to participate in any of these things. Has this turned into a phobia? Should the parents "cold turkey" the pull-ups?

Ann Fristoe, MDThousand Oaks, Calif.

A. Sounds like an extreme case of toilet training refusal. As the child is older than 4 and has normal development, she could walk out of your office today and get 99% of her stool and urine into the toilet or potty chair. However, we've all learned to proceed slowly in children who are both stool and urine holders. Here is what I would do:

During this time, and in the future, be sure the parents never remind her to use the toilet. That's the only way to dismantle the control issues. Just leave the potty chair in her favorite play area.

After she is happy with the above arrangement and is urinating and stooling at normal intervals again, train her for bladder control first. Let her continue to have diapers for poops, but tell her the pee wants to go in the toilet.

If she wets her underwear or holds back for more than four hours (or whatever her normal interval is), put her in "pee jail"-confined to one room, usually the kitchen, with a potty chair. While in pee jail she can look at books or play with a few toys, but she must be naked (not just bare-bottom). During this time, prime her kidneys with unlimited amounts of her favorite fluids.

The only way to get released from pee jail and get her clothes back is to pee into the potty chair. The supervising parent should not mention this unless the child complains that she wants to go elsewhere, in which case the parent should say "I'm sorry but your doctor said I can't let you out until you figure out how to make your pee go in the potty." Eventually the child will perform appropriately and be released. She can then be given a food treat such as ice cream.

If she wets her underwear after release from pee jail, it's back to square one. It's like taking a child back to her bedroom every time she comes out after saying good-night.

In the meantime, brainstorm some incentives for donating a poop to the family toilet-there has to be something that will turn her head. See my handout, "Using incentives to motivate your child"|~www.contemporarypediatrics.com/contpeds/data/articlestandard/contpeds/332004/112064/article.pdf in the April 2004 issue.

Bart Schmitt, MD

DR. SCHMITT is professor of pediatrics, University of Colorado School of Medicine, and Director of General Consultative Services, The Children's Hospital of Denver. He is a consulting editor for Contemporary Pediatrics.