By Steve Hodges, M.D.
Parenting advice columnists frequently attribute children’s toileting troubles — bedwetting, daytime accidents, incessant peeing — to psychological issues, such as stress, anxiety, and “heartache.”
For example, in response to a woman’s concern about her grandson's poop accidents, 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, she suggested “compassionate silence" — in other words, ignoring the accidents.
The same week, in another media outlet, a psychiatrist advised a parent concerned about her 4-year-old’s constant urination that the child “may be dealing with something that’s making him anxious.”
The assumption that psychological distress causes an overactive bladder or causes kids to poop in their pants is pervasive in our culture, despite being totally unfounded. No one even questions the assumption.
In movies and books, bedwetting is used as shorthand for psychological distress, and in politics, the term "bedwetting" has become a synonym for "excessive worry." Even in psychology and psychiatry literature — heck, on the American Academy of Pediatrics' own website — stress is often listed as a culprit or "risk factor" in bedwetting.
All this psychoanalyzing deprives children of effective treatment. Stress and anxiety are not causes of bedwetting, daytime pee accidents, poop accidents, or urinary frequency or urgency.
In reality, enuresis (bedwetting and daytime wetting), encopresis (chronic poop accidents), and urinary urgency or frequency are symptoms of a highly treatable medical condition: chronic constipation.
Many of my patients were referred for psychological or behavioral counseling by misinformed school personnel. They've been treated with art therapy and talk therapy when what they really needed was a regimen of laxatives and/or enemas to clear out a clogged rectum.
In constipated children, the rectum, enlarged by a pile-up of stool, presses against the bladder nerves, causing the bladder to suddenly and forcefully contract and empty, day or night. A stretched rectum also tends to lose sensation and tone, so kids stop sensing the urge to poop and are unable to fully evacuate. Poop piles up and drops out of their floppy rectum, without them even noticing, as I explain in the detail in the M.O.P. Anthology.
No amount of psychological counseling will change this scenario. The remedy is not "compassionate silence" but rather a bowel-emptying regimen such as the Modified O'Regan Protocol. In fact, ignoring accidents only permits the constipation to worsen, making accidents more challenging to treat in later years.
I appreciate that school counselors parenting experts urge compassion for children with toileting troubles. This is an improvement from the old-school attitude of the grandmother who wrote that her 4-year-old grandson "refuses" to poop on the toilet in order to "get back at his parents.”
In yet another media outlet, a parenting coach wrote that "the beauty of potty training is that it can reveal where a child is stuck.” In truth, a more accurate window into what’s triggering a child’s accidents is an abdominal x-ray.
I x-ray all my enuresis patients, and nearly all these x-rays reveal the child has a large mass of stool in the rectum. I also use x-rays to rule out the rare medical conditions that cause wetting in the absence of constipation, described in the M.O.P. Anthology.
Now, just because anxiety and stress don't cause toileting accidents doesn’t mean kids with enuresis and/or encopresis don’t feel distress. They absolutely do. But it's the accidents that cause the stress, not the other way around.
The older the child, the more acute the stress. Kids who have poop falling out of their bottoms or wet the bed are often 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
If you have assumed toileting accidents are caused by stress, you may find the following articles useful: