When young children refuse to poop on the potty, they have often fallen in to what I call the D-D-D cycle, for Discomfort > Dread > Delay. They might enter the cycle from any point, perhaps from waiting to poop because they don't want to interrupt playing, or perhaps from fear of the potty itself. But what these kids have in common is the uncomfortable passing of a large or hard stool. This can make them afraid the next time they need to go, which leads to stool withholding.

Then, when they finally do poop, it can be even more painful, reinforcing the dread and the delay. Researchers at the Children's Hospital of Philadelphia followed 380 children from before toileting was an issue all the way through successful potty learning, to see how children fall into this cycle. The results were published online in the June 2004 Pediatrics. The average age to complete daytime toilet learning was 36 months, and varied from 22 to 54 months. Along the way about one quarter of the kids experienced Stool Toileting Refusal (STR). For as many as 93 percent of the kids, the first step on the D-D-D cycle was the uncomfortable passing of a hard stool. This suggests that constipation may be inadequately addressed in children before they start to learn about going on the potty, and that solving the constipation problem may prevent many toilet difficulties that are commonly encountered.

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