The occurrence of specific behaviours for stool during toilet training (TT) might contribute to the development of stool problems like functional constipation (FC), withdrawal behaviour and functional fecal incontinence. (1) But to date, there is limited or outdated knowledge on phenomena like stool toileting refusal (STR), hiding while defecating and asking for a diaper for stool. (2, 3)
This research investigated the occurrence of these behaviours in normal developing children.

Parents of 3 to 5 year olds, attending kindergarten in Flemish schools, were retrospectively questioned by means of a questionnaire on the behaviour of their child during the TT period. 2917 questionnaires were distributed across 38 schools. A total of 1285 questionnaires were retrieved of which 57 were returned empty (42% response rate). After the exclusion of nine individuals, due to medical conditions, 1219 questionnaires remained eligible for further processing.

The questionnaires provided data on 1219 children (637 males and 581 females) with a mean age of 4.1 years. This study revealed a high prevalence of specific behaviours during TT: STR was marked in total in 23.5%, hiding while defecating in 13.1% and in 9.7% the child asked for a diaper when they felt the need to defecate. More detailed data on the frequency of the examined behaviours can be found in Table 1. No significant differences were observed between boys and girls.

This study showed the incidence of some challenging specific behaviours linked to the process of TT, like ‘hiding while defecating’, ‘stool toileting refusal’ (STR) and ‘asking for a diaper for defecation’, that might be risk factors for developing defecation problems after the completion of the TT process. 

We are convinced that more attention towards those specific behaviours and an appropriate management could possibly be beneficial for the child’s toileting habits. We even suppose that bowel problems in young children, could be diminished or even avoided if adequate mediation is implemented.

The different behaviours related to stool that occur during TT are quite common in normal developing children. Clear diagnostic criteria, especially for the variable “asking for a diaper”, are currently lacking. We recommend the use of the following definition: ‘When the child asks for a diaper, nappy or disposable underwear, instead of going to the toilet/potty when he or she has the need to defecate. This behaviour persists for at least one month’. 

These considerable prevalences may encourage further research to investigate the specific behaviours in order to avoid the development of stool problems at a later age.

Mugie SM, Di Lorenzo C, Benninga MA. Constipation in childhood. Nat Rev Gastroenterol Hepatol. 2011;8(9):502-11.
Blum NJ, Taubman B, Nemeth N. During toilet training, constipation occurs before stool toileting refusal. Pediatrics. 2004;113(6):e520-2.
Taubman B. Toilet training and toileting refusal for stool only: a prospective study. Pediatrics. 1997;99(1):54-8.