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  • By Steve Hodges, M.D.

Dear Parenting Experts: Please Stop Saying “Stress” Causes Potty Accidents


Ouch!

That was me tearing my hair out.

Twice this week in advice columns published in major media outlets, parenting experts have attributed children’s toileting troubles — poop accidents and too-frequent peeing — to psychological issues, such as stress, anxiety, and “heartache.”

In response to a woman’s concern about her grandson, a parenting coach wrote:

Four-year-old children have few communication tools available to them to express all of their big emotions. These emotions come spilling out in all kinds of inconvenient ways, and one of those is through defecating in inconvenient places at inconvenient times.

As a remedy for poop accidents and other potty issues, she suggested “compassionate silence.”

Also this week, a psychiatrist advised a parent concerned about her 4-year-old’s incessant urination that the child “may be dealing with something that’s making him anxious.”

Alternately, she wrote, the child may be peeing often as a way of earning rewards used during potty training. “To remedy this, you can stop giving him specific rewards for going.”

These parenting experts are misinformed, and seeking psychological explanations for physiological problems does these children a disservice.

Poop accidents happen when a child is severely and chronically constipated. Stretched by a pile-up of stool, the rectum loses tone and sensation. The child cannot detect when it’s time to poop, and stool drops out of the floppy rectum, often without the child even feeling it.

This condition is called encopresis. The remedy is not compassionate silence; it’s an enema regimen, and it works incredibly well.

Incessant peeing has the same cause as poop accidents: a clogged rectum. When a child pees literally minutes after he just peed, it’s almost always because a large, hard mass of poop is squishing and irritating his bladder. (Every once in a blue moon the cause is type 1 diabetes.)

This condition is called urinary frequency. The remedy is not easing his anxiety or eliminating rewards; it’s enemas or laxatives.

I appreciate that these parenting experts urge empathy and compassion for children with toileting troubles. This is an improvement from the old-school attitude of the grandmother who wrote to the parenting coach stating, “My 4-year-old grandson refuses to use the toilet to poop. He does it on purpose to get back at his parents.”

The parenting coach correctly stated that the child is not having accidents on purpose. But she’s off base when she says pooping in his pants is a “default reaction to a lack of better communication tools.”

Potty Problems Are Simpler Than They Appear

In my experience, many therapists and parenting coaches read far more into a child’s toileting issues than is warranted. I can't tell you how many of my patients have been referred to behavioral therapists for their bedwetting or accidents, when these problems were clearly caused by constipation and easily resolved with appropriate treatment.

Along these lines, the parenting coach wrote that the child’s accidents are “a reaction to heartache and whatever he is troubled by.”

“The beauty of potty training,” she observed, “is that it can reveal where a child is stuck.”

I don’t know — maybe the eyes are indeed a window into a person’s soul, but I can tell you that a child’s bottom is not!

If you want a more accurate window into what’s triggering a child’s accidents, examine an X-ray of her abdomen.

I examine these all day long, and here’s what I see: baseball-sized masses of poop stretching the rectum, the way a rat stretches a snake’s belly. I see bladders virtually flattened by stool-engorged rectums.

In the vast majority of cases, the parents and referring pediatricians did not even notice the child was constipated, and the behavioral therapist, if one was involved, never thought to ask. Chronically clogged children often poop daily, sometimes two or three times a day, because their rectums have lost the tone to fully empty. Adults tend to focus on how often a child poops, not what comes out.

I know it's difficult to believe that a toilet-trained child could repeatedly poop in his pants without any psychological issues going on. It seems impossible! But in fact, it's very easily explained and, with the right treatment, easily fixed.

I suggest that when a toilet-trained child has accidents, parenting experts spend less time urging parents to investigate what may be worrying their children and more time urging them to peer into the toilet bowl after their kids poop.

Do they see XXL toilet-cloggers? Do they see rabbit pellets? Hard logs? Turkey sausages?

All these are giant red flags for constipation, no matter how often a child poops.

The shape and consistency of poop also tell you that the child is likely in pain on the toilet — not psychological pain but “Ouch, my bottom hurts!” pain.

When stool piles up and hardens, pooping is painful, so the child will avoid it at all costs. So even more stool piles up, and then it hurts even more to poop. And so on — until the stool mass aggravates the bladder and/or stretches the rectum so much that poop drops out.

(Why does poop pile up in the first place? Three reasons, explained here.)

When Potty Training “Regression” is Actually Progression — Of Constipation

If stress plays a role in triggering accidents, it is likely early in the cycle — for example, when a child is pushed too hard to toilet train (see: potty bootcamps). There are many ways that stress can contribute to constipation (though I would submit that a highly processed diet and/or early toilet training contribute more).

However, even children who are toilet trained in a gentle manner can become severely constipated if they are trained too soon. My research has found that children trained before age 2 have triple the risk of developing daytime wetting problems down the line.

By “down the line” I mean a year, two years, even three years later. It can take that long for chronic constipation to trigger noticeable symptoms, like accidents or incessant peeing.

I see kids who potty trained early and easily, “practically by themselves,” according to their moms, only to start having accidents at age three or four.

Often the “regression” their parents observe is actually a progression — of constipation. Typically the sudden accidents have nothing to do with the arrival of a new baby or the start of a new school (though those events may affect a child who's in the middle of toilet training). Look at the X-rays of toilet-trained children and you can see what’s really going on.

However, just because anxiety and stress aren’t causing their problems, doesn’t mean these children don’t feel anxiety and stress. Often they do; it’s just that parenting experts have it flipped around: Stress doesn’t cause accidents; accidents can cause stress.

And the older the child, the more severe the stress. Kids who have poop falling out of their bottoms, pee every five minutes, or wet the bed get mercilessly teased, feel isolated because they can’t go on sleepovers, and generally feel crummy about themselves. At least that’s what I observe in my clinic, and it's why I wrote Bedwetting and Accidents Aren't Your Fault.

I have no shortage of teenage bedwetting patients who’ve been told all their lives that stress and anxiety are causing their problems and have visited multiple therapists.

Guess what happens when their rectums get cleaned out, shrink back to size, and stop bothering their bladders?

They are no longer stressed!

It’s a terrible feeling, even for a 4-year-old, to have no control of your bladder and bowels. So it is not surprising that children who have accidents display frustration.

Don’t Ignore Potty Accidents

The parenting coach noted that she frequently gets questions about potty issues and doesn’t like to address them. “Why? Many ‘training’ solutions often turn into yet another problem to deal with, and I hate the thought of adding to parenting woes.”

I, on the other hand, love to address potty issues because I know these problems are absolutely fixable. By far the most reliable fix is a regimen called the Modified O’Regan Protocol.)

I’m no parenting expert — ask my wife! — so there’s nothing I have to offer children who do suffer from heartache and anxiety. But give me a child who poops in his pants, and I can get that child squared away in a matter of weeks.

Parents worry endlessly that their children aren’t keeping up with their peers, which I suspect is why parenting experts frequently assuring parents that their child’s accidents are “normal.” As the psychiatrist wrote: “Most potty-related issues make parents more worried than they need to be. Setbacks and obstacles are completely normal, and they are not a reflection of your parenting skills!”

I agree that toileting problems are not a reflection of parenting skills, but the rest is backward: Toileting problems are NOT normal (common to the point of being epidemic, yes, but definitely not normal). And parents should be more, not less, concerned when a child poops in his pants or pees every five minutes. Ignoring these issues allows them to worsen with time.

If we stopped automatically attributing toileting problems to stress and started focusing on what actually causes them — constipation — children could get treated in a timely and appropriate manner and be on their way. Instead, families are sent in the wrong direction or simply urged to “wait it out,” and these kids don’t get help. In an extreme case, a child even died from severe constipation that had gone unrecognized.

The parenting coach wrote: “Reframe this issue so that you see a stressed-out child.”

I say: Reframe this issue so you see a constipated child, and get that child treated.

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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

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Feel free to contact Dr. Hodges or Suzanne directly:
shodges@wakehealth.edu
suzanne@bedwettingandaccidents.com

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