When Toilet Training Becomes a Battle: Understanding PDA, Anxiety, and Toilet Refusal

You've tried the rewards.

You've tried the sticker charts, the timers, the potty books, and the bathroom schedules.

You've encouraged. You've celebrated.

You've backed off, took a break, and then tried again.

But somehow, something that should be a normal part of childhood has turned into one of the most stressful parts of your day.

Maybe your child screams when you mention the bathroom.

Maybe they hide when they need to poop, refuse to sit on the toilet, or will only have a bowel movement in a diaper.

Maybe they were making progress, and suddenly everything stopped.

Or perhaps you're a therapist working with a child who has made very little progress despite weeks or months of intervention.

You've tried the strategies you were taught. You've adjusted the plan. You've educated the parents.

But the child is still refusing, and the family is becoming increasingly frustrated.

What if the problem isn't that the child won't cooperate? What if something about toileting feels so uncomfortable, overwhelming, or threatening that avoiding it has become the child's way of coping?

This is where we need to look beyond traditional potty training strategies.

Because for some children, particularly those with autism, anxiety, sensory processing differences, or a demand-avoidant profile, toilet training involves much more than learning where to go to the bathroom.

And the harder we push, the more difficult it can become.

When Toilet Refusal Is More Than a Behavior

When a child refuses to use the toilet, it's easy to focus on the behavior we can see.

The child runs away.

They say no.

They cry, scream, negotiate, or refuse to enter the bathroom.

They may even appear perfectly capable of using the toilet but insist on wearing a pull-up.

From the outside, this can look like stubbornness or defiance.

But refusal tells us what the child is doing. It doesn't tell us why.

There may be many underlying factors contributing to toileting resistance:

• Fear of falling into the toilet or losing control.

• A history of painful bowel movements or constipation.

• Sensory discomfort associated with the bathroom.

• Difficulty recognizing or interpreting bladder and bowel sensations.

• Anxiety about releasing urine or stool.

• Challenges with transitions and changes in routine.

• Difficulty understanding or responding to expectations.

• A strong need for predictability, autonomy, or control.

For many children, several of these factors overlap.

And when we focus only on getting the child to sit on the toilet, we can miss the very things that are preventing progress.

Understanding PDA and Toilet Training

PDA is commonly used to describe pathological demand avoidance, although some people prefer the term persistent drive for autonomy.

It is often discussed in connection with autism and describes a pattern in which everyday expectations or perceived demands may trigger significant anxiety, avoidance, or distress.

PDA is not currently recognized as a separate diagnosis in major diagnostic manuals, and researchers and clinicians continue to debate its definition and underlying mechanisms.

However, the challenges described by families are important to understand.

For some children, even ordinary requests can feel overwhelming.

And think about how many demands are involved in toileting.

"Go sit on the potty."

"Try before we leave."

"You need to use the bathroom."

"Just sit for a few minutes."

Even when these requests are reasonable, they may feel threatening or overwhelming to a child who experiences significant demand-related distress.

The child may resist, negotiate, become upset, or completely shut down.

The challenge may not be that the child doesn't know how to use the toilet. The challenge may be that the expectation itself creates anxiety.

And once toileting becomes associated with pressure or conflict, avoidance may increase.

Why More Rewards, Reminders, and Pressure May Make Things Worse

Imagine being afraid of something.

Now imagine someone reminding you throughout the day that you need to do that very thing.

They offer rewards.

They encourage you.

They remind you how important it is.

They tell you that you can do it.

Their intentions are good.

But instead of feeling supported, you begin to feel more anxious.

For some children, this is exactly what happens during toilet training.

A sticker chart or reward may work beautifully for one child.

For another, it may become another expectation they feel unable to meet.

A bathroom timer may help one child anticipate a transition.

For another, it may become a repeated reminder of something they fear.

The strategy isn't necessarily wrong. It may simply be the wrong strategy for that child's underlying needs.

This is why individualized assessment matters so much.

We need to understand what is driving the refusal before deciding how to intervene.

The Connection Between Anxiety, Constipation, and Stool Withholding

One of the most challenging toileting patterns I see involves children who refuse to poop on the toilet.

Some children will urinate without difficulty but insist on having bowel movements in a diaper.

Others hide, stand in a particular position, cross their legs, or actively try to prevent stool from passing.

Sometimes this begins after a painful bowel movement.

The child remembers the discomfort and begins avoiding the experience.

Unfortunately, withholding can make constipation worse, which may lead to larger or harder stools and additional pain.

A difficult cycle can develop:

Pain or fear → Withholding → Constipation → More discomfort → Greater fear and avoidance

Over time, the child may become increasingly anxious about toileting.

And even after constipation improves, the fear or learned avoidance may remain.

This is why we cannot treat every case of stool withholding as a behavioral problem.

Persistent constipation, painful bowel movements, stool leakage, urinary symptoms, or significant withholding should be evaluated by the child's healthcare provider.

Therapy strategies and medical management often need to work together.

Does Regulation-First Mean We Never Place Demands on a Child?

This is something I think is especially important to clarify.

Sometimes, a regulation-based or neurodiversity-affirming approach is interpreted to mean that we should never place expectations on a child, never use schedules, and simply wait until the child decides they are ready.

But that isn't what a Regulation-First approach means.

Structure and regulation are not opposites.

In fact, for many children, predictable routines can be incredibly regulating.

A familiar routine helps a child understand what is coming next, what is expected, and what will happen during an activity.

That predictability can reduce uncertainty and create a greater sense of safety.

Even children with PDA traits or significant demand avoidance may benefit from structure when it is introduced thoughtfully, collaboratively, and with appropriate flexibility.

The key is recognizing the difference between providing structure and creating pressure.

A structured toileting plan might include:

• Predictable bathroom opportunities throughout the day.

• Visual schedules or familiar cues.

• Consistent toileting routines.

• Choices that support autonomy.

• Comfortable positioning and sensory accommodations.

• Gradual skill development.

• Consistent communication across home, school, and therapy.

But these strategies should never involve forcing a distressed child to sit, ignoring signs of discomfort, or escalating demands when the child is overwhelmed.

For some children, we may begin by simply making the bathroom feel comfortable again.

For others, we may use short, predictable toileting opportunities that are gradually expanded as participation improves.

Regulation-First doesn't mean removing structure. It means using structure in a way that supports regulation, learning, and independence.

Six Strategies to Help Children Who Refuse the Toilet

1. Stop Asking Only, "How Do I Get This Child to Sit?"

Instead, begin asking:

"What is getting in the way of this child being able to participate?"

Is it fear?

Sensory discomfort?

Constipation?

Difficulty understanding the routine?

Anxiety about releasing stool?

Demand-related distress?

The answer will help determine which strategies are appropriate.

2. Identify the Child's Sensory and Emotional Triggers

The bathroom can be an overwhelming environment.

Consider the sound of flushing, bright lighting, smells, cold surfaces, uncomfortable toilet seats, and the sensation of clothing being removed.

Some children may also be uncomfortable with the physical sensation of releasing urine or stool.

Simple changes can make toileting more manageable.

A footstool, supportive toilet seat, quieter environment, or predictable bathroom routine may reduce discomfort.

For children with significant fear, gradual exposure to the bathroom environment may be necessary before expecting toilet sitting.

3. Change How You Communicate Expectations

For children who experience significant demand-related distress, the language we use can influence participation.

Instead of repeatedly saying, "You need to go sit on the potty," consider approaches that reduce unnecessary pressure.

For example:

"The bathroom is available when you're ready."

"Would you like me to come with you or wait outside?"

"Let's look at our routine and decide what comes next."

Some children benefit from choices.

Others prefer visual reminders, indirect language, or advance notice.

And some children may perceive even a choice as a demand.

The goal is not to disguise expectations or manipulate the child into compliance.

It's to find a communication approach that supports understanding, autonomy, and participation.

4. Build Predictable Routines Without Creating Power Struggles

For children with developmental delays, autism, or limited awareness of bladder and bowel sensations, routine can be an essential part of learning.

A child may not independently recognize when they need to use the bathroom.

But they may gradually learn the sequence of entering the bathroom, managing clothing, sitting comfortably, and participating in toileting.

Predictable opportunities can also help families identify natural bowel and bladder patterns.

For children who experience anxiety, we may need to begin with smaller steps and gradually build participation.

The routine should be consistent enough to support learning but flexible enough to accommodate the child's emotional and physical needs.

5. Support Regulation Before Expecting Participation

When a child is highly distressed, overwhelmed, or fearful, participating in toileting can become much more difficult.

This doesn't mean we have to eliminate every expectation.

It means we need to consider whether the child has the support necessary to participate.

Some children may benefit from movement before entering the bathroom.

Others may need a familiar caregiver, a visual routine, a preferred calming activity, or a quieter environment.

Co-regulation, predictable transitions, and sensory accommodations may help reduce distress.

The goal isn't to make the child compliant. It's to help the child feel safe enough to participate and learn.

6. Measure Progress Beyond Successful Toileting

When a child has significant toilet refusal, progress may look different from what parents and therapists initially expect.

Progress might include:

• Entering the bathroom without distress.

• Tolerating the toilet seat.

• Sitting briefly and comfortably.

• Participating in clothing management.

• Communicating the need to use the bathroom.

• Showing less fear around bowel movements.

• Recognizing body sensations.

• Participating in a consistent toileting routine.

These are meaningful steps.

And for some children, they are the foundation for eventually achieving greater toileting independence.

What If Your Child Is Older and Still Refusing the Toilet?

Toilet refusal doesn't automatically disappear when a child gets older.

Some school-aged children and teenagers continue to experience significant anxiety, sensory discomfort, constipation, or demand-related distress.

By this point, families may have tried numerous approaches.

The child may have experienced years of conflict around toileting.

And parents may feel discouraged or unsure whether further progress is possible.

But age alone should never determine whether a child can benefit from toileting intervention.

The goals may look different depending on the child's abilities, but meaningful progress can still include improved comfort, communication, participation, and independence.

For older children, it's especially important to respect privacy, dignity, and autonomy while providing developmentally appropriate support.

If you're working with an older child who continues to struggle, I recently wrote another article that explores this topic in more detail:

Read: Toilet Training Older Children With Autism, Cognitive Delays, and Complex Needs

For Therapists: When the Strategies You've Learned Aren't Working

One of the hardest parts of being a therapist is working with a child who isn't progressing despite your best efforts.

You've tried the strategies.

You've modified the environment.

You've educated the parents.

But the child is still refusing, and you're wondering what you're missing.

This is where clinical reasoning becomes so important.

Instead of simply adding another intervention, we need to step back and evaluate the underlying contributors.

Is the primary barrier sensory?

Is there a medical concern?

Does the child have difficulty interpreting internal body sensations?

Is anxiety interfering with participation?

Are the expectations exceeding the child's current developmental abilities?

Or are several of these factors interacting?

The goal isn't to collect more strategies. It's to understand which strategies are appropriate for the child in front of you—and why.

That's the foundation of a Regulation-First™ approach to toileting.

Final Thoughts: When Toileting Becomes a Battle, Something Needs to Change

If every bathroom visit has become a struggle, it's easy to feel like nothing is working.

Parents may begin to dread the next accident or the next attempt to get their child onto the toilet.

Therapists may feel frustrated because the strategies that work for other children aren't making a difference.

And the child may be experiencing fear, discomfort, confusion, or overwhelm that they cannot fully explain.

But more pressure isn't necessarily the answer.

And neither is giving up on teaching the skill.

The answer begins with understanding what is getting in the way.

When we identify the underlying barriers, support regulation, and create individualized opportunities for learning, we can begin moving away from daily battles and toward meaningful progress.

Because toilet training should not be about winning a power struggle.

It should be about helping a child develop the comfort, confidence, skills, and support they need to participate in toileting as independently as possible.

Ready to Move Beyond the Toileting Battles?

For Parents: You Don't Have to Keep Guessing What to Try Next

Maybe you've reached the point where you dread bringing up the bathroom.

You're tired of the accidents, the withholding, the tears, and the daily negotiations.

You worry about your child going to school, visiting friends, or becoming more independent.

And perhaps the hardest part is wondering whether you're doing enough—or whether your child will ever get past this.

You don't need another generic potty training checklist. You need an approach that helps you understand why your child is struggling and what to do next.

Potty Without Pressure

My Potty Without Pressure program was created to help parents move beyond traditional potty training strategies and understand the underlying challenges that may be interfering with toileting.

Rather than focusing only on rewards, timers, and getting your child to sit, you'll learn to consider nervous system regulation, sensory processing, body awareness, anxiety, and the developmental skills involved in toileting.

Because the goal isn't simply to get your child to use the potty. It's to help them develop the skills and confidence to participate without turning every bathroom visit into a battle.

Explore Potty Without Pressure

Need More Individualized Help? Let's Look at Your Child's Specific Challenges.

Sometimes you've read the articles, tried the programs, and followed the recommendations, but your child is still struggling.

Maybe you're dealing with significant stool withholding, severe anxiety, complex developmental needs, or years of unsuccessful toilet training attempts.

And what you really need is someone to help you figure out what's getting in the way for your child.

Through my individualized toileting consultations, we can look more closely at your child's challenges, identify potential barriers, and develop practical strategies that fit your child's abilities and your family's daily routines.

You don't have to keep trying one strategy after another without understanding why progress isn't happening.

Learn About Individualized Toileting Consultations

For Therapists: What Happens When Your Next Strategy Doesn't Work Either?

You know the child.

The one whose parents are looking to you for answers.

The child who refuses the toilet, withholds stool, or becomes overwhelmed every time toileting is mentioned.

You've tried the visual schedules, rewards, sensory strategies, and parent education.

And despite your best efforts, progress is limited.

You care about this child. You want to help this family.

But you're beginning to wonder whether there's something you're missing.

What if the missing piece isn't another activity or reward system, but a deeper understanding of why this child is struggling?

That's why I created the Toilet Training Success Academy (TTSA).

This isn't simply a collection of potty training tips.

It's a clinical education pathway designed to help therapists strengthen their assessment, clinical reasoning, and intervention planning for children with complex toileting challenges.

You'll explore how regulation, interoception, sensory processing, anxiety, developmental abilities, and other contributing factors can influence toileting—and how to use that understanding to develop individualized intervention plans.

Because families don't just need someone to tell them to try another sticker chart.

They need therapists who can help them understand what's getting in the way and develop a plan that makes sense for their child.

If you're ready to feel more confident approaching challenging toileting cases, I'd love to help you develop those skills.

Explore the Toilet Training Success Academy Certification

About the Author

Kathleen Yopp, MOT, OTR/L

Kathleen Yopp is a pediatric occupational therapist with over 28 years of experience specializing in emotional regulation, sensory processing, feeding challenges, toileting, and executive functioning. She is the founder of Helping Hands Therapy Services and creator of the Regulation-First™ approach.

Through her clinical practice, professional certification programs, and parent education resources, Kathleen helps therapists and families move beyond traditional strategies to understand the underlying challenges affecting children's participation, development, and independence.