More advice on a child who avoids public toilets

Allow me to add to Dr. Zuckerman's recommendations for the 4-year-old girl who refuses to use the toilet anywhere but home (Behavior: Ask the experts, June 2005).

Often, parents never think to model using the toilet at friends' homes and in public places. Encourage the parents to use public toilets almost every time they are away from home, including at grocery stores, shopping malls, and pizza places. Modeling is often the most powerful tool that we have. No need for the parents to lecture-just use the toilet!

Anxious children typically do much better in a familiar setting than in a less familiar one. So, initially encourage the child to use one of the other toilets in his or her home (assuming there is more than one). Then, encourage the child to use a toilet at the home of a grandparent or close friend. Over the course of a couple of weeks, the parents should gradually increase the child's exposure to toilets that are in more and more public places. Never increase the difficulty of the setting (how public a setting the toilet is in) until the child has been successful in a less difficult setting. Again, mom or dad should model using the public toilet before the child does. The parents can reward the child for increasingly difficult toilet exposures, but they shouldn't overdo it.

If the child is still not making progress at that point, referral to a behavior therapist experienced in treating anxiety and anxiety-related issues in children may be indicated.

Edward R. Christophersen, PhD

DR. CHRISTOPHERSEN is professor of pediatrics at The Children's Mercy Hospital, Kansas City, Mo.