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Section 13
Psychological Adjustment: Toileting Problems

Question 13 | Test | Table of Contents

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In the last section, we discussed eating difficulties.  These included picky eating, overeating and undereating.

Do you have a client whose newly-adopted child does not know how to use a toilet or is constantly bedwetting?  How do you respond?  In this section, we will discuss toileting problems.  These will include different customs, bedwetting, the training technique, soiling and intestinal difficulties.  As you listen, think of your client.  What suggestions do you make?

One area of adjustment that catches many new families unawares is toileting.  Difficulties range from differences in customs to the smearing of feces.  Toileting problems may be difficult for parents to handle because a child’s behaviors or problems may not be age-appropriate.  When parents adopt and infant, they expect to change diapers, but they may be unpleasantly surprised when they have to deal with a seven-year-old who soils his pants.

4 Toileting Problems of Newly-Adopted Children

♦ #1 Different Customs
First, let’s discuss different customs.  For international adoptees, toileting customs may be a problem.  In many parts of the world, as you know, a toilet is simply a hole in the ground or floor that the person squats over.  Some children may have never seen an American toilet and may have no idea how to use it.  The obvious solution for many kids is to simply climb atop it and squat.  Some families have had success simply showing their children how to use a toilet the "western" way.  For other families, the children watch the explanations and then proceed to do it the way that is comfortable for them.

Sabrina, age 39, a single mother, adopted SanSandeep (SAHN Sandeep), age 8, from India.  Sabrina stated, "I’m fairly sure that Sandeep is still standing on the toilet seat when he uses the bathroom, after almost a year.  I always find his shoes on the floor by the toilet.  I figure we have enough to worry about without worrying about what he does in the bathroom."

I stated, "With time, Sandeep will likely learn how to sit on the toilet, especially if any of his friends at school see him squatting atop it.  Remember, too, that this is a matter of comfort.  If you traveled to India to get Sandeep, you may well know how difficult it can be to squat over a hole in the floor.  Likewise, Sandeep may find it uncomfortable to sit on the toilet, which forces him use a different set of muscles."

Sabrina also described difficulties in teaching Sandeep to use toilet paper.  Sabrina stated, "When Sandeep first arrived at my house, I don’t think he even knew what toilet paper was.  I think Sandeep used his hand and a pitcher of water, or simply didn’t clean himself at all!"  I stated, "You may find it helpful to do a small educational routine showing Sandeep the appropriate use of the toilet and toilet paper, and the proper way to thoroughly wash his hands afterwards."

♦ #2 Bedwetting
Second, Sabrina and I discussed Sandeep’s bedwetting, or enuresis.  Bedwetting tends to run in families.  Unfortunately for adoptive parents, it is rarely known whether a child’s birth family has a history of bedwetting.  This made it difficult to determine if Sandeep was wetting the bed because he was more prone to it biologically or whether his bedwetting signaled an underlying physical or emotional problem. 

I stated, "If Austin wets the bed for any length of time, you may want to rule out possible medical causes.  Many ailments can cause or aggravate bedwetting, including diabetes, seizure disorders, sickle cell anemia, kidney failure, spina bifida, mental retardation, and autism.  Once you have ruled out medical causes, you can safely assume that the cause is psychological."  Many adopted children have bedwetting problems.  At times, such problems clear up after the initial adjustment period.  I explained that perhaps Sandeep was unsettled by the move and had regressed in his toilet habits.  For other children, however, bedwetting has deeper origins and lasts longer.

Suppressed or ignored anger may be one cause of bedwetting.  Some children who experience feelings of anger and worthlessness may not feel comfortable showing their feelings in a forthright way.  Such children may exhibit anger through passive aggressive behavior.  Children who feel worthless may use bedwetting and other behaviors as a means to provoke punishment.

Children who have been abused may find it difficult to distinguish their body’s messages, such as the sensation of a full bladder.  If this is the case, the child is likely to have wetting problems day and night.  Children who have been abused also may wet themselves as a way to keep people at a distance.  Abused children may learn that the smell makes people not want to be close.

I stated to Sabrina, "Dealing with bedwetting may leave you exhausted and angry.  One step you might take is to teach Sandeep how to strip and remake his own bed, so that you do not have to be awakened each night to do it.  You can also show Sandeep how to operate the washing machine to alleviate some of the laundry load.  Doing so may motivate him to help you in resolving the problem."

I continued to state, "If it appears that Sandeep is using bedwetting as a release of anger, dealing with the underlying anger may be the best way to alleviate it.  You can point out things that are obviously making Sandeep angry, by saying something like, ‘I can see that it makes you angry when your friends at school say that.’  Some children have never been able to or allowed to express their anger openly, and may have to be gradually taught how to do so.  You can encourage Sandeep to stomp his or her feet, beat his or her pillow, take a walk, pound nails, or hit baseballs.  As Sandeep finds more appropriate ways to express anger, his bedwetting may stop."

♦ Technique: Training
Sabrina felt that Sandeep was unaware of his body’s sensations as he also experienced daytime bedwetting, so I suggested that she try the Training Technique with Sandeep. 

I stated, "Sandeep might need to be cued to recognize feelings of fullness or pain, or the need to go to the bathroom.  You might try using a toilet training program similar to one you would use with a toddler.  First, teach him to go at set intervals, so that he can learn what it feels like to empty his bladder.  With time, he should be able to recognize when he has to go.  Remember that toilet training can take a year or longer with toddlers, and it may take time with Sandeep, too.  Bedwetting problems that subside may crop up again later, especially during emotional crises."

♦ #3 Soiling
Third, in addition to different customs and bedwetting, let’s discuss soiling.  Bowel control problems may accompany enuresis or appear by themselves.  Children can use bowl problems also as a means of control.  Some parents report that their children smear feces around the bathroom or on the floor and walls.  Other kids have purposely stopped up toilets with large amounts of toilet paper, much of it smeared with feces.  This type of behavior may indicate sexual or physical abuse.  At the same time, you’ll need to find ways to deal with the behavior at home.

Lola and Brent, both age 42, were the adoptive parents of two children, ages 9 and 11.  Lola stated, "We had a period of the toilet being stuffed to the very brim with wadded toilet paper, feces on the toilet paper, feces on the sink.  It could have been hostility to yet another placement, we don’t know.  Brent and I sat both of the children down and talked with them about what was an appropriate amount of toilet paper to use, what you do if our bowels are runny, versus what you do if you are constipated. 

"Brent and I coped with it by making the children responsible for cleaning it up.  We tried, and I think we were successful, not to condemn the children or punish them.  But it didn’t work!  We saw that behavior probably a dozen times before it just went away on its own!  We had the same conversation three or four times and then one day it just stopped."

Some parents advise putting the child back in diapers, calmly giving him or her the choices of going in a diaper or in the toilet, and making the child responsible for cleaning up any messes. This type of approach works well for some.  However, other children will continue to have difficulties until the underlying issues are addressed and resolved.

♦ #4 Intestinal Difficulties
Fourth, in addition to different customs, bedwetting and soiling, many families report that their children have intestinal difficulties upon arrival.  Constipation is common, especially among international adoptees.  One reason may be that long plane rides can seriously dehydrate the body, with constipation as a result.  The difference in diet probably contributes as well.  Making sure that your child drinks enough water and eats foods with fiber generally clears up constipation.

A more common problem is diarrhea.  In some cases, this is probably the result of the fear and anxiety that accompany a move to a new home.  However, if it persists there is probably an underlying cause.  Some children may have undiagnosed food allergies, or lactose intolerance, the inability to digest the sugars in milk.  Also, many children, whether adopted internationally in the United States, may have parasites on their arrival.  If your child has persistent diarrhea, have your doctor test for parasites.

In this section, we have discussed toileting problems.  These have included different customs, bedwetting, the training technique, soiling and intestinal difficulties.

Peer-Reviewed Journal Article References:
Goldberg, A. E., & Smith, J. Z. (2013). Predictors of psychological adjustment in early placed adopted children with lesbian, gay, and heterosexual parents. Journal of Family Psychology, 27(3), 431–442.

Ji, J., Brooks, D., Barth, R. P., & Kim, H. (2010). Beyond preadoptive risk: The impact of adoptive family environment on adopted youth’s psychosocial adjustment. American Journal of Orthopsychiatry, 80(3), 432–442.

Melançon, F., Cossette, L., Smith, C., Beauvais-Dubois, C., Cyr, C., & Smolla, N. (2019). Parenting stress of adoptive mothers, mother–child conflict, and behavior problems during adolescence among international adoptees. Journal of Family Psychology, 33(8), 988–993.

Mruzek, D. W., Handen, B. L., Aponte, C. A., Smith, T., & Foxx, R. M. (2019). Parent training for toileting in autism spectrum disorder. In C. R. Johnson, E. M. Butter, & L. Scahill (Eds.), Parent training for autism spectrum disorder: Improving the quality of life for children and their families (pp. 203–230). American Psychological Association.

Ramzaoui, H., Faure, S., & Spotorno, S. (2021). Top-down and bottom-up guidance in normal aging during scene search. Psychology and Aging, 36(4), 433–451.

QUESTION 13
What are four toileting problems that adoptive parents face? To select and enter your answer go to Test.

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