Professor Tanya Byron is a Clinical Psychologist who specialises in working with children and adolescent. In her regular Ask Tanya column for The Times, she gives advice to the parents of a four year old who is potty trained, but refusing to use the toilet at nursery and having wee accidents at home.

Thank you to 'The Times Newspaper' for allowing us to share this article. 

Jasmine, the mum of a little boy writes:

Our young son is shy, has struggled to settle into nursery and now won’t use the lavatory.

My husband and I potty trained our son (now nearly four) in the summer of last year when he was two years and eight months old, and it was very straightforward. Then he started nursery in January. He really struggled with settling in because he is shy and hates direct attention. In the first few weeks he wouldn’t talk to anyone, wouldn’t eat anything all day (he has always been very fussy) and refused to use the toilet. The last part was a real surprise because he has always been happy to use any toilet.

Wee accidents at nursery 

Slowly he started to talk to the adults, and then the children, and he definitely has friends there. He also eats. However, the toilet continues to be so difficult. Because he wouldn’t use the toilet (and was getting upset when the staff encouraged him to) he started having accidents at nursery, and I would frequently have four or five pairs of pants and trousers to wash each day. However, he continued to be dry at home. Now he sometimes wees using the nursery toilet, but he continues to have accidents during the day.

And at home...

Upset boy Then, a few months ago, he started to have accidents at home too. This was a huge shock and, to be honest, my husband and I would get pretty cross with him because it felt almost deliberate or lazy. We are now much calmer and more patient — although it is difficult to maintain. He has frequent accidents at home and at nursery, and says that he doesn’t know when he needs a wee. Every day when he gets home from nursery he instantly needs to do a poo and it is explosive.

What can we do to help him?

The nursery has been supportive and we have collectively tried everything we can think of. The staff gave him his own cubicle, had times when he would be the only child in the toilets and put a picture of our family on the door to reassure him. I spent 40 minutes in the cubicle once showing him that it’s not scary, and using the toilet myself.
He is incredibly self-aware, and although we have a year before he starts school, I don’t want him to be having these issues that will be terrible for his confidence.

Professor Tanya Byron's response:

Your son is struggling with daytime wetting (or urinary incontinence), which affects one in ten children, who will pass urine unexpectedly during the day after successful potty training. I can understand your concern about this issue, but I want to reassure you that you can support your son and help him to feel more confident in using the toilet. With time his behaviour will change.

When supporting a child behaviourally, we have to be careful that we don’t overwhelm them with our interventions and conversations. 

My overriding impression is that, while you have a number of people engaged in supporting him (at home and at nursery), it is likely that this has become too much of an “issue”. What I mean is that, when supporting a child behaviourally, we have to be careful that we don’t overwhelm them with our interventions and conversations, so a behaviour that should be relaxed, almost unthinking, becomes a perceived problem because of all the special effort made to help to change it.

Responding to the behaviour

The key to behavioural intervention sits around the “operant conditioning paradigm”, which basically states that the response that follows a behaviour will determine over time whether that behaviour is strengthened or extinguished. I can see that at home and at nursery everyone is working to be positive and encouraging. There are issues, however, that need to be considered, including the consistency of the approaches of everyone supporting your son, and whether the many positive interventions are unwittingly maintaining the problem.

Decatastrophise the problem

You have been honest and shared how at times you and your husband have become frustrated with your son, and even though you are now calmer and more patient, you do at times find that difficult to maintain. This is the experience of many parents I work with and is generally based around frustration, the fear that nothing is changing and worries about the future. My advice is to decatastrophise the problem. It can and will change in time, so approach it in a consistently calm and measured manner. If your anxiety gets in the way it will only increase your son’s anxiety and so reduce the chance of the problem (which is underpinned by his anxiety) being resolved.

A consistent, calm approach

However, before exploring a calmer, more consistent and less overwhelming management plan for your son, it is important that you rule out underlying medical conditions such as diabetes, and physical issues including bladder or nerve problems, for example an overactive bladder (frequently squeezing), an underactive bladder (not sensing an urge to urinate when the bladder is full), dysfunctional elimination syndrome (the bladder muscles tightening, stopping the flow of urine when there is urine in the bladder), a urinary tract infection and constipation causing problems when a full bowel presses on the bladder.

Toilet anxiety

Indeed, from what you describe, it sounds as though your son’s anxiety about using the toilet causes him to withhold, which leads to the frequent urination accidents and the explosive poos after nursery. It may be useful to check that he hasn’t become impacted (this is possible, even if he does poo every day), because this could be part of the problem.
I would then start tackling the problem at home, where your son is more likely to be relaxed — children often take behaviours newly learnt at home into other environments. Choose a weekend when you can record his weeing accidents, make no comment except to assure him that they really don’t matter, then change him with as little fuss and bother as possible. You will then have a baseline and can work out the shortest time he can remain dry for.

Using a reward strategy 

Reward on pinboardStart a sticker chart, with a sticker initially being given for the shortest period of dryness, to make it as easy as possible for him to stay dry. He can then exchange the stickers for a favourite activity, going to bed ten minutes later, playing a favourite game or having extra stories etc. Start the exchange rate low — initially he could exchange each sticker for a “treat”, then after he gets two dry periods consecutively that could be the exchange rate, and so on.

When he is reasonably accident-free at home, he could be rewarded with stickers at nursery to be exchanged at home — that is if the new behaviour doesn’t transfer to nursery. I would suggest a sticker for a dry morning and another for a dry afternoon. What, of course, is hugely important throughout is that the only comment you make if he wets himself is that you really don’t mind; the more relaxed you can be, the more he will be too.

In terms of using the toilet, I suggest you prompt him to sit (not more than once an hour) and have books or blowing bubbles in the lavatory so it’s fun and he’s distracted from feeling worried. Reward him for sitting with a sticker, regardless of whether he goes or not. At nursery they could do the same and just encourage him to go with his friends, and if he sits he could get a sticker to exchange at home. 

Further advice from ERIC 

Show young children our Wee and Poo characters to help them understand how to manage their bladder and bowel.

Share our free Potty Training Policy Package with your child's nursery, pre-school or childminder