Trust me: The child's accidents have nothing to do "potty training" and everything to do with chronic, severe constipation.
The other day I received an email from a distraught Atlanta mom. Her 5-year-old is about to be suspended from preschool for having too many accidents. "If he is not potty trained after Christmas break," the school wrote, "we will have to ask him not to return to school until he is. We hope you understand."
My first reaction: No, the school needs to understand. The child's accidents have nothing to do "potty training" and everything to do with chronic, severe constipation. The boy has no control over his accidents, and ultimatums will not change that.
My second reaction: Oh, man, here we go again.
Five years ago, 3 ½-year-old Zoe Rosso was told not to return to her Arlington, Virginia, preschool until she stopped wetting her pants. Zoe, whose plight made the Washington Post, was deemed "not potty trained."
Except that, like the Atlanta boy, she was.
Zoe, who later became my patient, had a Nerf-basketball-sized mass of stool clogging her rectum and flattening her bladder. An X-ray confirmed Zoe had no chance of staying dry until her rectum was cleaned out and given time to shrink back to size, as it eventually did.
While suspending preschoolers for accidents may not be commonplace, I know from experience that preschools are in serious need of education on toileting matters. Even schools with a relaxed approach to potty training often miss the signs of chronic constipation, priming children for pee accidents (enuresis) or poop accidents (encopresis) or enabling cases to worsen.
Here's what every preschool director, teacher, and parent should know.
Virtually all accidents and bedwetting episodes are caused by chronic constipation.
What appears to be potty-training "regression" is usually the progression of constipation. A few years may pass between the end of potty training and the start of accidents, but eventually, the holding habit catches up with the child. Poop piles up, and the hard mass aggravates the bladder.
In the Atlanta boy's case, the stool mass also has stretched his rectum so much that it has lost tone and sensation. Poop just drops out, and the boy can't feel it. This scenario is quite common.
Accidents are not caused by psychological or behavioral issues.
Schools routinely attribute accidents to stress or, worse, "laziness" or "willfulness." They often refer families for psychological counseling, which is about as useful as trying to fix diabetes with talk therapy.
Yes, children with enuresis and encopresis often feel stressed and act out, but it's because they are blamed for a condition they can't control.
Preschools assume these children are refusing to use the toilet. In reality, they can't feel when they need to poop, and when a child's bladder has gone haywire, pee accidents happen spontaneously.
Preschools that require potty training by age 3 do a huge disservice to children.
I realize it's convenient—and less expensive, staffing-wise—for preschools to have potty-trained children. But arbitrary dryness deadlines prompt parents to start training their children too early.
Children trained before age 2 have triple the risk of later developing daytime wetting problems, my research has found. Most children under 3, especially those under 2, simply can't respond to their bodies' urges to pee and poop in a judicious manner. So, many become chronic holders.
Threats and ridicule don't help resolve toileting accidents.
Children who have accidents are frequently humiliated by school personnel. At pick-up, Zoe Rosso's teacher would broadcast Zoe's accident tally for the day. Another mom told me her son's teacher would make the class stand in the hallway while the boy "cleaned himself up from his accident."
No wonder this poor child was having trouble making friends. It was incidents like these that prompted me to write Bedwetting and Accidents Aren't Your Fault. Kids internalize the blame.
What You Can Do
If your child has been threatened with suspension or subjected to ridicule for toileting issues, I urge you to advocate for your child. Here's how:
Get a proper diagnosis.
Many physicians, totally missing the boat, attribute accidents to an "underdeveloped bladder" and insist the child will outgrow the problem. Or, they may dismiss constipation as the cause because they use worthless diagnostic techniques. (It doesn't help to feel child's belly or ask how often the child poops.)
Insist on an X-ray. A rectum wider than 3 cm indicates constipation. In children who have accidents, the rectum is often 6 or 7 cm wide.
Have your child's doctor write a letter explaining the diagnosis.
I write these notes all the time, and they're usually enough to make a school back off. Some schools are even grateful for the education.
Make sure your child receives proper treatment.
The most reliable, lasting way to resolve accidents is a daily enema regimen. This sounds "extreme," but research shows it works and is safe. When constipation has progressed to the point of accidents, a healthy diet and daily dose of Miralax won't suffice.
After two weeks of daily enemas, the Atlanta boy's poop accidents already have ceased. Pee accidents (and bedwetting) take longer to resolve. I hope the boy's school gives him time.
Know your legal rights.
An encopresis or enuresis diagnosis may qualify your preschooler for protection under the Americans with Disabilities act, depending on several variables. The ADA hotline (800-514-0301) offers personalized advice.
K-12 students with diagnosed toileting difficulties may be eligible for a 504 plan, requiring the school to make certain accommodations.
Zoe Rosso's mom, Betsy, got nothing but grief from the school and other parents. One Washington Post commenter called her "lazy." Another wrote, "It's narcissistic for parents to insist their untrained child has to be indulged."
Our schools, and our culture, need to stop judging families and start learning the facts. Some compassion would be nice, too.
Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine. He is the co-author, with Suzanne Schlosberg, of It's No Accident and Bedwetting and Accidents Aren't Your Fault. His website is bedwettingandaccidents.com.