Complications and Side Effects Associated with a Lack of Toileting Skills

  • Russell Lang
  • Laurie McLay
  • Amarie Carnett
  • Katherine Ledbetter-cho
  • Xiaoning Sun
  • Giulio Lancioni
Part of the Autism and Child Psychopathology Series book series (ACPS)


Individuals who do not acquired toileting skills during early childhood are at an increased risk for medical complications, social exclusion, and an overall diminished quality of life. Persistent toileting skill deficits may be caused by physiological abnormalities that complicate or prevent successful voiding of the bowel and bladder. Additionally, an individual may learn to withhold stool or urine or to engage in other behaviors that preclude successful elimination in the toilet. Frequently, physiological and learning factors act in tandem to create toileting difficulties. This chapter first addresses medical issues that may contribute to and/or arise from toileting difficulties. The remainder of the chapter focuses on the psychological and social domains that may be negatively impacted by the failure to acquire hygienic toileting skills.


Toileting Incontinence Encopresis Complications Toilet Training Side Effects 


  1. Baeyens, D., Roeyers, H., D'Haese, L., Pieters, F., Hoebeke, P., & Walle, J. (2006). The prevalence of ADHD in children with enuresis: Comparison between a tertiary and non tertiary care sample. Acta Paediatrica, 95, 347–352.CrossRefPubMedGoogle Scholar
  2. Baber, K. F., Anderson, J., Puzanovova, M., & Walker, L. S. (2008). Rome II versus Rome III classification of functional gastrointestinal disorders in pediatric chronic abdominal pain. Journal of Pediatric Gastroenterology and Nutrition, 47, 299–302.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Berry, A. (2005). Helping children with dysfunctional voiding. Urologic Nursing, 25, 193–202.PubMedGoogle Scholar
  4. Blum, N. J., Taubman, B., & Nemeth, N. (2004). During toilet training, constipation occurs before stool toileting refusal. Pediatrics, 113, 520–522.CrossRefGoogle Scholar
  5. Bongers, M. E., van Wijk, M. P., Reitsma, J. B., & Benninga, M. A. (2010). Long-term prognosis for childhood constipation: Clinical outcomes in adulthood. Pediatrics, 126, 156–162.CrossRefGoogle Scholar
  6. Bower, W. F., Sit, F. K., , & Yeung, C. K. (2006). Nocturnal enuresis in adolescents and adults is associated with childhood elimination symptoms. The Journal of Urology, 176, 1771–1775.CrossRefPubMedGoogle Scholar
  7. Brazelton, T. B., Christopherson, E. R., Frauman, A. C., Gorski, P. A., Poole, J. M., Stadtler, A. C., & Wright, C. L. (1999). Instruction, timeliness, and medical influences affecting toilet training. Pediatrics, 103, 1353–1358.PubMedGoogle Scholar
  8. Butler, R., & Heron, J. (2008). An exploration of children’s views of bed-wetting at 9 years. Child: Care, Health and Development, 34, 65–70.Google Scholar
  9. Caldwell, P. H. Y., Hodson, E., Craig, J. C., & Edgar, D. (2005). Bedwetting and toileting problems in children. The Medical Journal of Australia, 182, 190–195.PubMedGoogle Scholar
  10. Chase, J. W., Homsy, Y., Siggaard, C., Sit, F., & Bower, W. F. (2004). Functional constipation in children. The Journal of Urology, 171, 2641–2643.CrossRefPubMedGoogle Scholar
  11. Christophersen, E. R. (1991). Toileting problems in children. Pediatric Annals, 20, 240–244.CrossRefPubMedGoogle Scholar
  12. Clarke, M. C. C., Chow, C. S., Chase, J. W., Gibb, S., Hutson, J. M., & Southwell, B. R. (2008). Quality of life in children with slow transit constipation. Journal of Pediatric Surgery, 43, 320–324.CrossRefPubMedGoogle Scholar
  13. Cohen, S. A., Hendricks, K. M., Mathis, R. K., Laramee, S., & Walker, W. A. (1979). Chronic nonspecific diarrhea: Dietary relationships. Pediatrics, 64, 402–407.PubMedGoogle Scholar
  14. Cook, I. J., Talley, N. J., Benninga, M. J., Rao, S. S., & Scott, M. M. (2009). Chronic constipation: Overview and challenges. Neurogastroenterology and Motility, 21, 1–8.CrossRefPubMedGoogle Scholar
  15. Cooper, C. S., Hoebeke, P., Vande Wall, J., Bishop, W. P., Bower, W. F., & Austin, J. C. (2002). Current management of dysfunctional voiding. Dialogues in Pediatric Urology, 25, 1–8.Google Scholar
  16. Cox, D. J., Morris, J. B., Borowitz, S. M., & Sutphen, J. L. (2002). Psychological differences between children with and without chronic encopresis. Journal of Pediatric Psychology, 27, 585–591.CrossRefPubMedGoogle Scholar
  17. Deshpande, A. V., & Caldwell, P. H. (2012). Medical management of nocturnal enuresis. Pediatric Drugs, 14, 71–77.CrossRefPubMedGoogle Scholar
  18. Driver, D. S. (2007). Perineal dermatitis in critical care patients. Critical Care Nurse, 27, 42–46.PubMedGoogle Scholar
  19. Elder, J. S., Peters, C. A., Arant Jr., B. S., Ewalt, D. H., Hawtrey, C. E., Hurwitz, R. S., …, & Hasselblad, V. (1997). Pediatric vesicoureteral reflux guidelines panel summary report on the management of primary vesicoureteral reflux in children. The Journal of Urology, 157, 1846–1851.Google Scholar
  20. Feehan, M., McGee, R., Stanton, W., & Silva, P. (1990). A 6-year follow-up of childhood enuresis: Prevalence in adolescence and consequences for mental health. Journal of Pediatrics and Child Health, 26, 75–79.CrossRefGoogle Scholar
  21. Frauman, A. C., & Brandon, D. H. (1996). Toilet training for the child with chronic illness. Pediatric Nursing, 22, 469–472.PubMedGoogle Scholar
  22. Frauman, A. C., & Myers, J. T. (1994). Cognitive, psychosocial, and physical development in infants and children with end-stage renal disease. Advances in Renal Replacement Therapy, 1, 49–54.CrossRefPubMedGoogle Scholar
  23. Garman, K., & Ficca, M. (2012). Managing encopresis in the elementary school setting the school nurse’s role. The Journal of School Nursing, 28, 175–180.CrossRefPubMedGoogle Scholar
  24. Guarino, A., Lo Vecchio, A., & Canani, R. B. (2012). Chronic diarrhoea in children. Best Practice and Research Clinical Gastroenterology, 26, 649–661.CrossRefPubMedGoogle Scholar
  25. Har, A. F., & Croffie, J. (2010). Encopresis. Pediatrics in Review, 31, 368–374.CrossRefPubMedGoogle Scholar
  26. Hellerstein, S., & Linebarger, J. S. (2003). Voiding dysfunction in pediatric patients. Clinical Pediatrics, 42, 43–49.CrossRefPubMedGoogle Scholar
  27. Hirasing, R. A., van Leerdam, F. J., Bolk-Bennink, L. B., & Bosch, J. D. (1997). Bedwetting and behavioral and/or emotional problems. Acta Paediatrica, 86, 1131–1134.CrossRefPubMedGoogle Scholar
  28. Hoberman, A., Chao, H. P., Keller, D. M., Hickey, R., Davis, H. W., & Ellis, D. (1993). Prevalence of urinary tract infection in febrile infants. Journal of Pediatrics, 123, 17–23.CrossRefPubMedGoogle Scholar
  29. Hyman, P. E., Milla, P. J., Benninga, M. A., Davidson, G. P., Fleisher, D. F., & Taminiau, J. (2006). Childhood functional gastrointestinal disorders: Neonate/toddler. Gastroenterology, 130, 1519–1526.CrossRefPubMedGoogle Scholar
  30. Issenman, R. M., Filmer, R. B., & Gorski, P. A. (1999). A review of bowel and bladder control development in children: How gastrointestinal and urologic conditions relate to problems in toilet training. Pediatrics, 103, 1346–1352.PubMedGoogle Scholar
  31. Issenman, R. M., Hewson, S., Pirhonen, D., & Taylor, W. (1987). Are chronic digestive complaints the result of abnormal dietary patterns? American Journal of Diseases of Children, 141, 679–682.CrossRefPubMedGoogle Scholar
  32. Joinson, C., Heron, J., Butler, U., & von Gontard, A. (2006). Psychological differences between children with and without soiling problems. Pediatrics, 117, 1575–1584.CrossRefPubMedGoogle Scholar
  33. Joinson, C., Heron, J., Emond, A., & Butler, R. (2007). Psychological problems in children with bedwetting and combined (day and night) wetting: A UK population-based study. Journal of Pediatric Psychology, 32, 605–616.CrossRefPubMedGoogle Scholar
  34. Joinson, C., Heron, J., & von Gontard, A. (2006). Psychological problems in children with daytime wetting. Pediatrics, 118, 1985–1993.CrossRefPubMedGoogle Scholar
  35. Kajiwara, M., Inoue, K., Usui, A., Kurihara, M., & Usui, T. (2004). The micturition habits and prevalence of daytime urinary incontinence in Japanese primary school children. Journal of Urology, 167, 1069–1073.Google Scholar
  36. Kasirga, E., Akil, I., Yilmaz, O., & Polat, M. (2006). Evaluation of voiding dysfunctions in children with chronic functional constipation. Turkish Journal of Pediatrics, 48, 340–343.PubMedGoogle Scholar
  37. Kelly, C. (1996). Chronic constipation and soiling in children: A review of the psychological and family literature. Child Psychology and Psychiatry Review, 1, 59–66.CrossRefGoogle Scholar
  38. Kistner, M. (2009). Dysfunctional elimination behaviors and associated complications in school-age children. The Journal of School Nursing, 25, 108–116.CrossRefPubMedGoogle Scholar
  39. Koff, S. A., Wagner, T. T., & Jayanthi, J. R. (1998). The relationship among dysfunctional elimiation syndromes, primary vesicoureteral reflex and urinary tract infections in children. The Journal of Urology, 160, 1019–1022.CrossRefPubMedGoogle Scholar
  40. Levine, M. D., & Bakow, H. (1976). Children with encopresis: A study of treatment outcome. Paediatrics, 58, 845–897.Google Scholar
  41. Loening-Baucke, V. (1993). Constipation in early childhood: Patient characteristics, treatment, and long-term follow-up. Gut, 34, 1400–1404.CrossRefPubMedPubMedCentralGoogle Scholar
  42. Loening-Baucke, V. (1997). Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics, 100, 228–232.CrossRefPubMedGoogle Scholar
  43. Loening-Baucke, V. (2005). Prevalence, symptoms, and outcome of constipation in infants and toddlers. Journal of Pediatrics, 146, 359–363.CrossRefPubMedGoogle Scholar
  44. Loening-Baucke, V., & Swidsinski, A. (2007). Constipation as a cause of acute abdominal pain in children. The Journal of Pediatrics, 151, 666–669.CrossRefPubMedGoogle Scholar
  45. Mellon, M. W., Natchev, B. E., Katusic, S. K., Colligan, R. C., Weaver, A. L., Voigt, R. G., & Barbaresi, W. J. (2013). Incidence of enuresis and encopresis among children with attention-deficit/hyperactivity disorder in a population-based birth cohort. Academic Pediatrics, 13, 322–327.CrossRefPubMedGoogle Scholar
  46. Moukarzel, A. A., Lesicka, H., & Ament, M. E. (2002). Irritable bowel syndrome and nonspecific diarrhea in infancy and childhood: Relationship with juice malabsorption. Clinical Pediatrics, 41, 145–150.CrossRefPubMedGoogle Scholar
  47. Murphy, K. P., Boutin, S. A., & Ide, K. R. (2012). Cerebral palsy, neurogenic bladder, and outcomes of lifetime care. Developmental Medicine and Child Neurology, 54, 945–950.CrossRefPubMedGoogle Scholar
  48. Palmer, M. H., Athanasopoulos, A., Lee, K. S., Takeda, M., & Wyndaele, J. J. (2012). Sociocultural and environmental influences on bladder health. International Journal of Clinical Practice, 66, 1132–1138.CrossRefPubMedGoogle Scholar
  49. Partin, J. C., Hamill, S. K., Fischel, J. E., & Partin, J. S. (1992). Painful defecation and fecal soiling in children. Pediatrics, 89, 1007–1009.PubMedGoogle Scholar
  50. Peeters, B., Noens, I., Kuppens, S., & Benninga, M. A. (2016). Toilet training in children with a functional defecation disorder and concomitant symptoms of autism spectrum disorder. Research in Autism Spectrum Disorders, 26, 91–98.CrossRefGoogle Scholar
  51. Philips, E. M., Peeters, B., Teeuw, A. H., Leenders, A. G., Boluyt, N., Brilleslijper-Kater, S. N., & Benninga, M. A. (2015). Stressful life events in children with functional defecation disorders. Journal of Pediatric Gastroenterology and Nutrition, 61, 384–392.CrossRefPubMedGoogle Scholar
  52. Procter, E., & Loader, P. (2003). A 6-year follow-up study of chronic constipation and soiling in a specialist pediatric service. Child: Care, Health, and Development, 29, 103–109.Google Scholar
  53. Rajindrajith, S., Devanarayana, N. M., Weerasooriya, L., Hathagoda, W., & Benninga, M. A. (2013). Quality of life and somatic symptoms in children with constipation: A school-based study. Journal of Pediatrics, 163, 1069–1072.CrossRefPubMedGoogle Scholar
  54. Rasquin, A., Di Lorenzo, C., Forbes, D., Guiraldes, E., Hyams, J. S., Staiano, A., & Walker, L. S. (2006). Childhood functional gastrointestinal disorders: Child/adolescent. Gastroenterology, 30, 1527–1537.CrossRefGoogle Scholar
  55. Rasquin-Weber, A., Hyman, P. E., Cucchiara, S., Fleisher, D. R., Hyams, J. S., Mills, P. J., & Stalano, A. (1999). Childhood functional gastrointestinal disorders. Gut, 45, 1160–1168.CrossRefGoogle Scholar
  56. Read, N. (2012). Irritable bowel syndrome in children explained. Community Practitioner, 85, 40–41.PubMedGoogle Scholar
  57. Redsell, S. A., & Collier, J. (2001). Bedwetting, behaviour and self-esteem: A review of the literature. Child: Care, Health and Development, 27, 149–162.Google Scholar
  58. Reiner, W. G., & Gearhart, J. P. (2006). Anxiety disorders in children with epispadias-exstrophy. Urology, 68, 172–174.CrossRefPubMedGoogle Scholar
  59. Robinson, J. C., Butler, R. J., Holland, P., & Doherty- Williams, D. (2003). Self-construing in children with primary mono-symptomatic nocturnal enuresis: An investigation of three measures. Scandinavian Journal of Urology and Nephrology, 37, 124–128.CrossRefPubMedGoogle Scholar
  60. Robson, W. L. (1999). Enuresis treatment in the US. Scandinavian Journal of Urology and Nephrology, 202, 56–60.CrossRefPubMedGoogle Scholar
  61. Rushton, H. G. (1993). Evaluation of the enuretic child. Clinical Pediatrics, 32, 14–18.CrossRefGoogle Scholar
  62. Sansome, A. (2011). Bladder and bowel management in physically disabled children. Paediatrics and Child Health, 21, 454–458.CrossRefGoogle Scholar
  63. Schonwald, A., Sherritt, L., Stadtler, A., & Bridgemohan, C. (2004). Factors associated with difficult toilet training. Pediatrics, 113, 1753–1757.CrossRefPubMedGoogle Scholar
  64. Schulman, S. L. (2004). Voiding dysfunction in children. Urologic Clinics of North America, 31, 481–490.CrossRefPubMedGoogle Scholar
  65. Schulpen, T. W. J. (1997). The burden of nocturnal enuresis. Acta Paediatrica, 86, 981–984.CrossRefPubMedGoogle Scholar
  66. Shah, G., & Upadhyay, J. (2005). Controversies in the diagnosis and management of urinary tract infections in children. Pediatric Drugs, 7, 339–346.CrossRefPubMedGoogle Scholar
  67. Shreeram, S., He, J. P., Kalaydjian, A., Brothers, S., & Merikangas, K. R. (2009). Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among US children: Results from a nationally representative study. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 35–41.CrossRefGoogle Scholar
  68. Stull, T. L., & LiPuma, J. J. (1991). Epidemiology and natural history of urinary tract infections in children. Medical Clinics of North America, 75, 287–297.CrossRefPubMedGoogle Scholar
  69. Tai, T. T., Tai, B. T., Chang, Y. J., & Huang, K. H. (2015). Parents have different perceptions of bed-wetting than children from six to 15 years of age. Acta Paediatrica, 104, 466–472.CrossRefGoogle Scholar
  70. Taubman, B., & Buzby, M. (1997). Overflow encopresis and stool toileting refusal during toilet training: A prospective study on the effect of therapeutic efficacy. The Journal of Pediatrics, 131, 768–771.CrossRefPubMedGoogle Scholar
  71. Theunis, M., Van Hoecke, E., Paesbrugge, S., Hoebeke, P., & Vande Walle, J. (2002). Self-image and performance in children with nocturnal enuresis. European Urology, 41, 660–667.CrossRefPubMedGoogle Scholar
  72. Tsutomu, K., & Fumiyuki, N. (2011). Effectiveness of parent-implemented interventions based on functional assessment of toilet skills in young children with autism. Japanese Journal for Behavior Analysis, 25, 153–164.Google Scholar
  73. Van den Berg, M. M., Benninga, M. A., & Lorenzo, C. (2006). Epidemiology of childhood constipation: A systematic review. The American Journal of Gastroenterology, 101, 2401–2409.CrossRefPubMedGoogle Scholar
  74. Van Hoecke, E., De Fruyt, F., De Clercq, B., Hoebeke, P., & Vande Walle, J. (2006). Internalizing and externalizing problem behavior in children with nocturnal and diurnal enuresis: A five-factor model perspective. Journal of Pediatric Psychology, 31, 460–468.CrossRefPubMedGoogle Scholar
  75. von Gontard, A., & Hollmann, E. (2004). Comorbidity of functional urinary incontinence and encopresis: Somatic and behavioral associations. The Journal of Urology, 171, 2644–2647.CrossRefGoogle Scholar
  76. von Gontard, A., Moritz, A. M., Thome-Granz, S., & Equit, M. (2015). Abdominal pain symptoms are associated with anxiety and depression in young children. Acta Paediatrica, 104, 1156–1163.CrossRefGoogle Scholar
  77. von Gontard, A., Moritz, A. M., Thome-Granz, S., & Freitag, C. (2011). Association of attention deficit and elimination disorders at school entry: A population based study. The Journal of Urology, 186, 2027–2032.CrossRefGoogle Scholar
  78. Wang, C., Shang, L. Zhang, Y., Tian, J., Wang, B., Yang, X., …, & Xu, Y. (2013). Impact of functional constipation in health-related quality of life in preschool children and their families in Xi’an, China. PloS One, 8, e77273.Google Scholar
  79. Wolfe-Christensen, C., Veenstra, A. L., Kovacevic, L., Elder, J. S., & Lakshmanan, Y. (2012). Psychosocial difficulties in children referred to pediatric urology: A closer look. Urology, 80, 907–913.CrossRefPubMedGoogle Scholar
  80. Yeung, C. K., Sit, F. K. Y., To, L. K. C, Chiu, H. N., Sihoe, J. D. Y., Lee, E., & Wong, C. (2002). Reduction in nocturnal functional bladder capacity is a common factor in the pathogenesis of refractory nocturnal enuresis. BJU International, 90, 302–307.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Russell Lang
    • 1
  • Laurie McLay
    • 2
  • Amarie Carnett
    • 3
  • Katherine Ledbetter-cho
    • 1
    • 4
  • Xiaoning Sun
    • 1
  • Giulio Lancioni
    • 5
  1. 1.Department of Special EducationClinic for Autism Research Evaluation and Support, Texas State UniversitySan MarcosUSA
  2. 2.University of Canterbury, College of Education, Health, and Human DevelopmentChristchurchNew Zealand
  3. 3.Department of Educational PsychologyUniversity of North TexasDentonUSA
  4. 4.The University of Texas at AustinAustinUSA
  5. 5.University of BariBariItaly

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