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  • By Steve Hodges, M.D.

Enough With Potty Bootcamps!

Our culture is enamored with lightening quick fixes for potty problems.

A New York City company was recently showered with publicity after launching a two-day, $1,750 toilet-training service — perceived as a godsend by moms “frustrated” by their potty-averse 3-year-olds.

Then USA Today touted a physician’s four-day fix-it program for encopresis (poop accidents). A 5-year-old following the program was instructed to spend three days in the bathroom with toys and a TV. After two days, the child was still having accidents, so her parents, under the doctor’s guidance, implemented “tough love” and removed the toys.

The accidents, the mother told her daughter, were “not acceptable.”

Here’s what is not acceptable — and is harmful to children: treating accidents as behavior problems. Also harmful: attempting to toilet train or fix toileting troubles on a deadline.

As a pediatric urologist who specializes in treating toileting dysfunction, I am distressed by the message that quick-fix programs send to both parents and children.

The message is this: If you, the parent, make a “total commitment” to the process and if your child is managed in just the right way, all potty issues will resolve asap. And if your kid continues to have accidents? Well, it’s because one of you isn’t trying hard enough.

This message is based on a faulty understanding of how the body works and what actually causes accidents. It also fosters unrealistic expectations that can prompt parents to lash out at their kids, sometimes physically, in frustration.

No, Potty Problems Are Not Caused by Behavioral or Psychological Issues

According to a pediatrician quoted in USA Today, encopresis treatment “has to tackle the behavioral issues that underlie a lot of the difficulties that lead to the refusal.” Wrong! The top reason children “refuse” to use the toilet is simply that pooping hurts them, because their stool has become hard.

The reason children have poop accidents is that stool has piled up in the child’s rectum, stretching the rectum to the point where it has lost tone and sensation. So, poop just drops out, and often the child can’t even feel it.

Wetting, whether daytime or at night, also is a red flag for constipation: The large, hard lump of poop that has accumulated in the rectum is pressing against the child’s bladder, shrinking its capacity and irritating the nerves that feed it.

The treatment for all this is straightforward — and not helped in any way by sticker charts or sentencing a child to sit in the bathroom for three days.

First, the large, hardened lump of stool must be cleared out so the rectum can shrink back to size, regaining tone and sensation. Second, the stool must be softened so that pooping no longer hurts.

The stool clean-out can be achieved either with a 24-hour, high-dose laxative regimen or, more effectively, with enemas. Yes, enemas!

A pediatrician quoted in USA Today insists enemas may be “very traumatic to the child.” This is false. Not only are enemas highly effective and perfectly safe when used as directed, but they also are not painful for children and in my vast experience do not bother children, let alone traumatize them.

When you explain to a child that enemas are the ticket to clean, dry underwear, they are plenty willing to give it a try. It’s typically when parents convey squeamishness or fear that kids pick up on it and become reluctant themselves. In my practice, the kids who get better the quickest are those who follow an enema regimen.

Once the child’s rectum is cleaned out, a daily laxative and high-fiber, whole-foods diet will keep the colon clear, as long as the child poops and pees with frequency.

A clogged rectum can be cleaned out in a day or two, and for some kids, that’s enough to stop the accidents. But for others, it can take weeks or even months for the rectum to shrink back to size and for bowel and bladder function to normalize. You simply cannot rush the process, even if you pay a potty training guru $1,750 or a doctor $450 for long-distance phone consultations.

You also cannot assume the program “worked” simply because your child emerges from a boot-camp accident free. In reality, children who are newly toilet trained or whose problems have newly resolved require constant monitoring, to make sure the child is not holding pee or poop. The glory may be short-lived if you don’t do the follow-through. That part is never mentioned in the media but is confirmed daily in my practice.

Potty Training Toddlers is Risky Business

Our culture is frantic about getting children toilet trained before age 3, on the theory that waiting longer makes the process more difficult. What irony! In fact, it’s this mad rush to train toddlers that is, in large part, fueling an epidemic of toileting problems.

In a published study conducted at my Wake Forest clinic, we found that children trained before age 2 have triple the risk of developing subsequent toileting difficulties compared to children trained between ages 2 and 3.

This is because toddlers are much more prone to hold their poop and pee than older children. Indeed you can train an 18-month-old to use the toilet, but knowing how to poop on the potty is not the same as responding to your body’s urges in a judicious manner.

Symptoms may not surface for two or three years, but the holding behavior so common among potty-trained 2-year-olds often catches up with these kids. That’s when they show up at my clinic, with the sudden onset of poop or pee accidents. Many parents have tried these boot-camp fixes, emerging even more frustrated.

In my opinion, children under age 3 should not be in charge of their toileting any more than they should be in charge of their college funds. Late trainers are much more ready than toddlers and less likely to withhold stool (and might do just fine in a 3-day program).

Yet 3-year-olds in diapers are stigmatized. Preschools with potty-training deadlines do children and parents a huge disservice by forcing the process.

In the USA Today article, one doctor calls untrained 3-year-olds “potty-refusers.” He goes on to say, “They know what to do, however they will fight you every step of the way.” Newsflash: If they are fighting you, it’s either because they aren’t ready to train or, more likely, they are severely constipated.

You can’t train a constipated child. It won’t work. In my study, 70 percent of the children who trained at age 3 or later had wetting problems. It’s not because their parents waited too long to train them but because all of the kids who developed wetting problems were constipated when the training started.

Studies that have investigated the ideal age for toilet training have consistently failed to consider the constipation status of children and whether they later developed toileting problems.

What’s the Rush?

As a dad, I understand the appeal of potty bootcamps. I have three young daughters, one still in diapers, and I look forward to the day when we ditch our diaper bag for good. But I’m not going to push her to train by 3 for my convenience.

We need to take a hard look at why we are forcing children to train on our schedule, not theirs. What is our motivation?

A doctor in the USA Today piece says the four-day program “is quick, but it’s not easy.” Actually, he’s got it backward. Treating encopresis is actually easy, but it’s often not quick. This emphasis on speed is harming children.

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Must-read books for kids by Steve Hodges, M.D.

• Bedwetting and Accidents Aren't Your Fault

• Jane and the Giant Poop