Can you force a 3-year-old with Down syndrome to be potty-trained?
According to the complaint, the school principal emailed the child’s parents with a deadline: “I was thinking April 1st? Since it is corporate policy, I have to set a time frame to get her potty trained.”
If the allegations are true, the suit is a no-brainer. “Corporate policy” cannot dictate the toileting development of a child with Down syndrome! But there’s a larger story here: Potty-training deadlines are inappropriate for any child, disabled or not.
Deadlines are convenient for preschools, and they may sound reasonable. However, they are based on a misunderstanding of toileting development and increase children’s risk for later developing enuresis (daytime pee accidents and bedwetting) and encopresis (poop accidents).
I frequently write letters on behalf of children issued toilet-training ultimatums after having accidents at school. Last month, in support of a severely constipated 4-year-old, I wrote to a school whose “firm” policy was to suspend children for a week or two “to complete their toilet learning” and then to expel these kids if they failed to stay dry.
The school insisted its policy was based on “best practices.” But from a pediatric urology perspective, suspending preschoolers for toileting issues is a dreadful practice.
Sending these kids home for a week to “work on” potty skills is like suspending dyslexic children for a week to work on reading. These kids will fail, because their problems are unrelated to a lack of training.
When a child struggles with toilet training, it means the child is either 1.) developmentally unready or 2.) chronically constipated. Either way, training is a doomed enterprise, and the consequences can be severe and long-lasting.
Ironically, potty deadlines are the very reason many children have accidents. By setting deadlines for 3-year-olds, schools prompt parents to start training their children at age 2 or 2½. The problem is, most toddlers—not just those with Down syndrome—aren’t ready. Yes, they’re physically capable of using the toilet, but that’s totally different from possessing the judgment to heed nature’s call in a timely manner.
Preschool potty mandates run up against a basic fact: Three-year-olds don’t like to use the toilet. They like to build towers and shop with toy grocery carts. At school they may feel too inhibited or excited to interrupt their play to use the toilet. So they develop the habit of holding both poop and pee.
Over time, poop piles up in the rectum, forming a large, hard lump that presses against and aggravates the bladder. Holding pee thickens and further irritates the bladder wall. The result: These kids end up with squished and hyperactive bladders that hiccup and empty without warning. With some kids, the stretched rectum loses tone and sensation, and poop falls out.
I have difficulty persuading preschools of this, because they don’t often see the consequences of their policies. Yes, some kids develop problems at age 3 or 4; those are the kids singled out and issued ultimatums. But with many kids, it takes until kindergarten or beyond for constipation to reach a crisis point.
My clinic is packed with school-age kids, including tweens and teens, who have accidents. Most of them were trained early to meet preschool deadlines.
My clinical experience and research indicate most children are ready to potty train around age 3, but this is not a hard-and-fast rule. In general, children should train when they show readiness—not in response to an arbitrary date on the calendar.
In addition to ditching potty deadlines, or at least easing up on enforcement, preschools can make a positive and lasting impact on children by teaching them healthy toileting habits. This is as important as teaching kids to count and use scissors!
I suggest preschools take these steps.
1. Teach children (and parents) to identify healthy poop.
Children should poop piles of mush, like soft-serve ice cream or soft, thin snakes. Preschools can post our How’s Your Poop? chart in their bathrooms.
2. Teach kids what happens when they keep poop and pee inside.
Preschoolers can understand the concept of poop piling up and forming a big, hard lump that stretches the rectum—like a rat in a snake’s belly—and squishes the bladder.
3. Schedule bathroom trips about every two hours.
Children need both opportunity and encouragement. Openly discussing bathroom habits in school on a regular basis helps.
4. Watch children closely for signs of constipation.
Pooping frequency is not a reliable measure of constipation. Severely constipated children can poop multiple times a day because they don’t fully evacuate. The top two signs of constipation are extra-large poops and poops that are formed, like pellets or logs. Other signs include urgent or frequent peeing, belly pain, and an itchy anus.
5. Instruct children to plant their feet on a tall stool when pooping.
Pooping in the squatting position straightens the rectum, allowing poop to fall out easily. Children can’t relax their pooping muscles when their feet are dangling.
6. Explain that accidents are never, ever a child’s fault.
Though many adults insist otherwise, potty accidents are not a sign of behavior problems, laziness, or lack of cooperation. They are not within the child’s control, and they are mortifying. Sending these children home with a deadline to attempt the impossible only adds to the shame they already feel. What these kids need is treatment for their constipation and loads of compassion.