Young girl won't use the toilet away from home

Q. My 4-year-old patient has been toilet trained for a year except that she refuses to use the toilet anywhere but home. She has gone as long as 15 hours without voiding; she complains of stomach pains when she holds urine for a long time but still waits until she gets home to void! The girl is developmentally appropriate for her age, has good social interactions, and is attentive to her 1-year-old brother, who has a metabolic disorder but is doing well. Any suggestions for approaching this problem, especially given the fact that she will be entering day care?

Judith Gorra, MD Lewes, Del.

A. Two issues need to be addressed: The mother's chief complaint about her daughter and the impact on the family of having a child with a metabolic disorder, which may or may not be related to the chief complaint.

The chief complaint is consistent with a phobia but a mild one, as the child's avoidance of the toilet interferes in only a small way with her daily activities. Unlike a fear, a phobia does not respond to reassurance or distraction, so the most important thing for the mother to do is respect the child's avoidance of toilets outside the house. One way for the mother to ensure that the problem persists is to focus on it and keep telling her daughter to try going to the toilet, or to show her concern and worry when the child refuses to void and expresses discomfort from holding urine.

You can also reassure the mother that such reluctance to use the potty is, at this age, normal. Again, the best thing is for the parents not to overreact-or not to react at all. Parents can't banish all fears and phobias, but they can support their child's efforts to cope with them. Emphasize in your discussion that the child is doing well and that, through socialization at day care or with the passage of time, she will use the potty away from home.

Barry Zuckerman, MD

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