There may already be stickers in the bathroom. A book beside the toilet. Perhaps an iPad that helps your child sit for a little while. You have tried to make the experience less frightening, and still there are poo accidents or small smears in their undies.
At this point, another suggestion can feel like another job.
In my work, I have seen how much effort families put into helping a child use the toilet. When progress is slow, I want to step back from the question of how to get the child to sit and ask what is making the whole process difficult.
This article focuses mainly on poo withholding and accidents, which are the difficulties I am describing here. Ongoing wetting or pain when doing a wee needs its own assessment; different toilet difficulties should not all be treated as the same problem.
The physical side
Check what is happening in the bowel
A child may hold on after a painful poo. The longer poo remains in the bowel, the harder it can become, making the next bowel movement uncomfortable too. Fear and withholding can then reinforce each other.
Small smears do not necessarily mean the child has chosen to poo in their pants. With constipation, softer poo can leak around retained stool. A child may also become less aware of the urge to go when the rectum has been stretched by a build-up of poo.
These are reasons to seek medical advice rather than assume that more encouragement, rewards or reminders will solve the difficulty. Repeated soiling, painful poos or persistent holding-on deserve a conversation with your GP or a clinician experienced in children's continence.
Where constipation is present, treatment may include prescribed medicines as well as a toileting plan. Diet and fluids matter, but they are not always enough on their own. Treatment often needs to continue beyond the first few successful toilet visits, with guidance from the treating clinician.
Being calm about an accident is helpful. Leaving a possible bowel problem unassessed is something different. We can take the pressure off the child while taking the physical difficulty seriously.
Comfort and the body
Sitting on the toilet is only one part of it
The steps we can see are familiar: go to the bathroom, pull clothes down, sit, do a poo. But the child also has to manage what is happening inside their body and how it feels to be on that toilet.
Interoception is the awareness of internal body signals, including bowel and bladder fullness. It is one part of the picture, not a diagnosis we can make simply because a child has accidents.
I pay attention to whether a child seems comfortable in their body, including how they are breathing. But observing shallow breathing does not establish the cause of constipation, and breathing exercises are not a substitute for bowel assessment or treatment.
Practical comfort is worth looking at. Can the child sit securely, or are they gripping the seat and trying not to slip? Are their feet supported? A suitable seat insert and a stable footstool, with the knees a little higher than the hips, can help a child sit more comfortably. Gentle, unforced breathing may help them relax; the aim is not to make them push harder or hold their breath.
For a child who is frightened of sitting, small, supported steps may still be useful. Making the bathroom more welcoming is a reasonable part of helping. The question is whether the plan also addresses pain, physical comfort and the child's individual needs.
Strategies that help
A helpful distraction does not have to become the whole plan
Some families find that a favourite activity makes toilet time more manageable. That help is not automatically a mistake. Using a distraction does not prove that a child cannot notice body signals, and there is no need to abruptly remove something that is helping them feel safe.
My concern is when all our attention goes into getting the child through the toilet visit, while the rest of their experience receives less attention. A child can be persuaded to sit and still be uncomfortable. A parent can carry out a complicated routine faithfully and still need a different kind of help.
I would want to understand what the strategy is doing. Does it help the child approach the bathroom? Stay comfortable for a brief sit? Recover from fear? It may be useful for one part of the task without solving everything. Continence guidance includes making the toilet environment welcoming alongside attention to posture and relaxation.
The same broader view applies outside the bathroom. I often think about opportunities for enjoyable movement, food and hydration, and whether the day leaves room for a child to feel unhurried. For one child, that might include outdoor play they can safely enjoy. Another child may need a quieter or differently adapted activity.
These are supports to consider alongside the child's care plan. Running, rolling or other movement should not be presented as a way to make constipation disappear or guarantee that toileting will follow naturally.
The next step
Make the next step manageable
A short record of bowel movements, accidents and discomfort can help a clinician understand the pattern. It does not need to become a detailed surveillance exercise. Note the things you are already noticing, including where toileting is easier and anything your child tells you.
Then choose a manageable next step with the professionals involved. That may be following a constipation treatment plan, improving the toilet setup, or adjusting an approach that has become too distressing. It does not have to mean introducing five new activities at once.
An OT can help look at the task, equipment and environmental demands. A GP or paediatric continence clinician can assess bowel or urinary symptoms and guide the medical side of care. Those roles can work together.
Seek urgent medical care for severe tummy pain, a child who appears very unwell, or vomiting with an inability to keep fluids down. Green vomit also needs urgent assessment. These are not difficulties to work through with a home toilet-training strategy.
Meanwhile, an accident can be met with practical help and privacy. The child needs to be comfortable and clean, without having the event turned into a judgement about effort or maturity.
Progress may begin before there is a completely dry, clean pair of undies at the end of every day. A less painful bowel movement, a more comfortable sit or being able to ask for help can matter. The aim is for using the toilet to become something the child's body can manage, with the support it needs, rather than another task everyone has to struggle through.