JAMA Netw Open. 2026 May 1;9(5):e2612390. doi: 10.1001/jamanetworkopen.2026.12390.
ABSTRACT
IMPORTANCE: Understanding toilet avoidance and stool withholding at school is essential, as this can adversely affect children’s health and well-being.
OBJECTIVE: To assess the prevalence of toilet avoidance and stool withholding at school, and to explore the differences of withholding behavior by gender and geographic location of the school, identify reasons for withholding, and describe physical symptoms and health care utilization.
DESIGN, SETTING AND PARTICIPANTS: This cross-sectional study used an online questionnaire developed by experts from Amsterdam University Medical Center and the Dutch Digestive Health Fund. Children aged 8 to 16 years from primary schools (aged 8-12 years) and high schools (aged 13-16 years) were recruited by Verian, an external research agency, through a nationwide online panel in the Netherlands.
EXPOSURE: In July 2024, school-aged children completed the questionnaire.
MAIN OUTCOMES AND MEASURES: The primary outcomes were the prevalence of stool withholding, reasons for withholding, gastrointestinal symptoms, and health care utilization. Secondary outcomes included differences between gender and geographic location of the school, children’s reasons for avoiding school toilets, and toilets’ perceived cleanliness. To assess potential differences in withholding behavior according to gender and geographic location, a Cochran-Armitage test was performed.
RESULTS: A total of 1000 children, 518 aged 8 to 12 years (264 [51.0%] male) and 482 aged 13 to 16 years (234 [48.5%] male) completed the questionnaire. Stool withholding was reported by 265 primary school children (51.2%) and 344 high school children (71.4%), with no significant differences by gender or geographic location. Hygiene and privacy concerns were the most commonly reported reasons for withholding stool with 610 (84.3%) of children accounting for hygiene and 574 (79.3%) citing privacy concerns, and 410 (41.0%) of children rated school toilet cleanliness as insufficient. Abdominal pain was frequently reported (365 of 724 [50.4%]) and 15 of 336 primary school children (4.5%) experienced fecal incontinence. Overall, 42 primary school children (12.5%) had consulted a physician for symptoms related to withholding.
CONCLUSIONS AND RELEVANCE: In this cross-sectional study, toilet avoidance and stool withholding at school were common among both primary and high school children, mostly due to hygiene and privacy concerns. Improving school toilet facilities may reduce withholding behavior, gastrointestinal symptoms, and related physician visits, thereby supporting children’s physical, psychological, and educational well-being.
PMID:42126876 | DOI:10.1001/jamanetworkopen.2026.12390
