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Children Who Hide While Defecating Before They Have Completed Toilet Training: a Prospective Study

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Children Who Hide While Defecating Before They Have Completed Toilet Training: a Prospective Study ARTICLE Children Who Hide While Defecating Before They Have Completed Toilet Training A Prospective Study Bruce Taubman, MD; Nathan J. Blum, MD; Nicole Nemeth, MD Objective: To examine the incidence and age at onset Results: Two hundred sixty-three children (69.6%) met of hiding while defecating in children before they have the criteria for the hiding group. The median age at ini- been toilet trained and its association with difficulties in tiation of hiding for the group was 22 months. Thirty- toilet training. eight began hiding before toilet training was initiated and 64 started hiding after intensive toilet training had be- Design: Prospective study. gun. The nonhiders (115 [30.4%]) were significantly less likely to have stool toileting refusal, frequent constipa- Setting: Suburban private pediatric practice. tion, or stool withholding. They also completed toilet training at an earlier age than the hiders (34.5±5.9 months Subjects: Three hundred seventy-eight children aged 17 vs 38.1±5.9 months; PϽ.001). to 19 months. Conclusions: The behavior of hiding while defecating Methods: Children were followed up by telephone in- before completion of toilet training is associated with terviews with the parents every 2 to 3 months until the child stool toileting refusal, constipation, and stool with- completed daytime toilet training. Children who were de- holding. These behaviors may make toilet training scribed at any follow-up telephone call as always or almost more difficult. always hiding when defecating prior to completing toilet training were defined as the hiding group. The remainder of the children, who were described as never hiding or only sometimes hiding, was defined as the nonhiding group. Arch Pediatr Adolesc Med. 2003;157:1190-1192 N OUR RESEARCH research on METHODS toilet training and in our clini- cal practice, we have ob- SAMPLE served that children often hide from the adults around Families of 408 consecutive 17- to 19-month- themI while defecating in their diapers.1,2 In old children from the private pediatric prac- a recent abstract, this behavior was found tice of one of us (B.T.) were asked to partici- to be associated with difficult toilet train- pate in a study designed to investigate factors ing, but we are unaware of any reports on related to age at completion of toilet training and to study an intervention designed to de- crease stool toileting refusal. Parents of 406 chil- See also pages 1153 dren gave written informed consent to partici- and 1193 pate in the study. Children with global developmental delays or structural abnormali- the incidence of this behavior, its age at on- ties of the spinal cord, genitourinary tract, or set, or other significant associations.3 This gastrointestinal tract were excluded. The pe- From the Divisions of behavior is of interest because training chil- diatric practice is in the suburbs of a major met- Gastroenterology and Nutrition dren for stool is often the major stumbling ropolitan area and serves predominantly (Dr Taubman) and Child block to successful toilet training.1,4,5 As part middle- and upper-middle-class families. More Development and Rehabilitation than 90% of the families are white, and the of a study investigating the effectiveness of 6 (Dr Blum) and The Children’s an intervention designed to decrease the in- mean±SD Hollingshead score was 52.4±10.8, Hospital of Philadelphia cidence of stool toileting refusal, we pro- which is near the top of social stratum IV of (Dr Nemeth), University of the 5-category index. Pennsylvania School of spectively observed 378 children through Twenty-seven families were lost to fol- Medicine, Philadelphia; and the toilet training process. This report de- low-up or stopped participating in the study the Cherry Hill Pediatric scribes the incidence and age at onset of hid- before the completion of toilet training. One Group (Dr Taubman), ing while defecating, and its association with child was dropped from the study because of Cherry Hill, NJ. toilet training difficulties. global developmental delays not apparent at the (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, DEC 2003 WWW.ARCHPEDIATRICS.COM 1190 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 time of enrollment. Three hundred seventy- eight (93%) were followed up until they completed daytime toilet training and Table 1. Sex and Toilet Training Behaviors are the subject of this article. The study was approved by the in Hiding vs Nonhiding Groups institutional review board of The Children’s Hospital of Phila- delphia, Philadelphia, Pa. Hiders Nonhiders (n = 263) (n = 115) P Value PROCEDURES Sex, % male 51.7 53.4 .82 Age at initiation of toilet 21.4 (2.7) 20.4 (2.2) .009 At enrollment, families were randomized to receive 1 of 2 in- training, mean (SD), mo tervention handouts. Both handouts emphasized a child- Age at initiation of intensive 28.9 (5.4) 28.2 (5.9) .347 oriented approach to toilet training consistent with published toilet training, guidelines.7 The intervention handout provided the addi- mean (SD), mo tional recommendation to increase praise for defecating and not Stool toileting refusal, % 29.4 16.0 .001 refer to stool in negative terms.2 Stool withholding, % 29.1 12.1 .001 We conducted follow-up telephone interviews every 2 to Constipation, % 62.2 39.6 Ͻ.001 Ͻ 3 months until the parents reported that the child had com- Age toilet trained, 38.1 (5.9) 34.5 (5.9) .001 pleted daytime toilet training at 2 consecutive interviews. Toi- mean (SD), mo let training was defined as completed when the child was wear- ing underpants whenever awake and had fewer than 4 urine accidents per week and 2 or fewer fecal soiling episodes per month. During the interviews, parents were asked whether they 100 had initiated toilet training and, if so, at what age and how of- ten they asked the child to sit on the toilet or potty. We de- fined the age at initiation of toilet training as the age at which parents took out a potty chair and began discussing some as- 75 pect of toilet training with the child. We defined the age at in- tensive toilet training as the age at which parents asked their child to use the toilet or potty more than 3 times a day. Parents were also asked whether their children had gone 50 off by themselves while having a bowel movement in the dia- per and, if so, whether they did so sometimes, almost always, No. of Children or always. Children who did so almost always or always for at least 1 month made up the hiding group. Those who never went 25 off by themselves or did so only occasionally made up the non- hiding group. In addition, information was obtained about constipa- tion, stool withholding, and stool toileting refusal. Children were 0 coded as being constipated if parents ever reported hard bowel 17 21 25 29 33 37 41 movements at a follow-up interview. Stool toileting refusal was Age at First Hiding for Defecation, mo scored as occurring when a child refused to defecate in the toi- Number of children who first started hiding for defecation at each age level. let or potty for longer than 1 month after meeting the criteria for daytime toilet training for urine. Stool withholding was scored as occurring if the child engaged in a physical activity such as crossing of the legs or running around to avoid having a bowel though there was no difference in the age at initiation of movement in the diaper or pull-on disposable underwear. intensive training (Table 1). The median age for initia- tion of hiding was 22 months, and the distribution of ages STATISTICS for initiating hiding was skewed, as shown in the Figure. Thirty-eight children began hiding before toi- Statistical analyses were preformed with SPSS version 9.0 (SPSS Inc, Chicago, Ill). The group who hid during the toilet train- let training was initiated; 64 children began hiding after ing process was compared with the group who did not. For di- intensive toilet training was initiated. chotomous variables, the ␹2 statistic was used, and for con- The nonhiders were significantly less likely to have tinuous variables the unpaired t test was used. P values less than stool toileting refusal, constipation, or stool withhold- .05 were considered statistically significant. ing during the toilet training process (Table 1). They also completed toilet training at a significantly earlier age RESULTS (Table 1). Since stool toileting refusal has been associ- ated with constipation and delayed toilet training, we ana- There was no difference in the incidence of hiding dur- lyzed the data excluding children with stool toileting re- ing defecation between the intervention group (68.4%) fusal.1,8 Children in the hiding group still trained later and the control group (70.4%); therefore, the 2 groups and had a higher incidence of constipation and stool with- were combined for this analysis. Two hundred sixty- holding (Table 2). three children (69.6% of the sample) met the criteria for being in the hiding group. There was no significant dif- COMMENT ference in sex distribution between the hiding and non- hiding groups (Table 1). For children in the hiding The phenomenon in children of hiding while defecating group, parents reported initiating toilet training at a in their diaper has, to our knowledge, not previously been slightly greater age than in the nonhiding group, al- described in any detail. The only reference to this be- (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, DEC 2003 WWW.ARCHPEDIATRICS.COM 1191 ©2003 American Medical Association.
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