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Toilet Refusal Syndrome in Preschool Children: Do Different Subtypes Exist?

Niemczyk, Justine; Equit, Monika; El Khatib, Diana; von Gontard, Alexander

Journal of Pediatric Gastroenterology and Nutrition: March 2014 - Volume 58 - Issue 3 - p 303–306
doi: 10.1097/MPG.0000000000000204
Original Articles: Gastroenterology

Objectives: Toilet refusal syndrome (TRS) is a common, benign disorder in toddlers defined by the use of diapers and refusal of toilet for defaecation, but has not been described systematically in preschool children yet. The aim of the study was to analyse and identify possible subgroups of TRS.

Methods: Retrospective analysis of all of the consecutive children with TRS presented as outpatients in a clinic for elimination disorders. Patients had received a detailed paediatric and child psychiatric assessment, including the Child Behavior Checklist questionnaire. Three typical case vignettes are presented of TRS with constipation, oppositional defiant disorder, and sibling rivalry.

Results: Twenty-five children (10 boys) with a mean age of 5.2 (3.4–7.3) years were included—representing 2.5% of all of the children (n = 1001) presented. They had high rates of constipation (60%) and elimination disorders (24%–44%). Child psychiatric International Classification of Diseases-10th Edition disorders were common (40%) and heterogeneous, with significantly more boys affected, but no differences between children with and without constipation.

Conclusions: This study shows that TRS occurs also in older preschool (and even school) children. At this later age, it is associated with constipation and behavioural disorders. The case vignettes show differences in therapy and may represent different subgroups of TRS. TRS is associated with constipation, elimination disorders, and psychiatric disorders. Owing to this variety of comorbid disorders, different therapeutic approaches are needed. A general screening for behavioural symptoms is recommended.

Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany.

Address correspondence and reprint requests to Justine Niemczyk, Department of Child and Adolescent Psychiatry, Saarland University Hospital, 66421 Homburg, Germany (e-mail

Received 5 October, 2013

Accepted 5 October, 2013

The authors report no conflicts of interest.

© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,