A Diaper Fading Protocol to Treat Toilet Refusal: Four Case Studies

Childhood constipation and painful defecation is common, affecting 68% to 86% of children. Over 90% withhold stool, some only defecating in a diaper. Behavioral therapy is effective for encopresis, but there is minimal research on treating toilet avoidance. This study investigates a novel protocol to eliminate diapers in children with toilet avoidance.

A diaper fading protocol was used with four children with toilet avoidance. Children were instructed to defecate in the bathroom, moving progressively closer to the toilet until they eventually sat on the toilet with the diaper. As needed, diapers were then faded by cutting increasingly wider slits in the base of the diaper so that stool could pass into the toilet. The cut widened until the diaper was eliminated entirely.

Four children (three boys, average 5.22 years old) successfully completed toilet training using the diaper fading protocol in an average of 9.75 sessions. Delivery of treatment via telehealth was shown to be effective. The diaper fading protocol effectively and flexibly assisted toilet training in four children with stool withholding and toileting avoidance. Future work should investigate whether caregivers can utilize the protocol without ongoing support, or on a consultation basis only, to reduce the burden on health care workers with long waitlists.