Yesterday I received an email from a mom who has been issued an ultimatum by her daughter’s preschool. The mom wrote: “Our daughter has one month to display fully potty-trained behaviors, or she will be disenrolled.”
I get emails like this every fall and have written extensively on one of the more egregious examples of preschool potty crackdowns. These stories follow the same rough outline: A child has multiple accidents at school, the school declares the child “not potty trained,” and the director pulls out the school’s toileting policy — the one all parents signed — to justify the ultimatum.
The policy at the 4-year-old’s preschool is as follows:
“If a child has multiple accidents in a day or over a period of days, and we realize a child is not fully toilet trained, then we may ask that parents keep the child home for a week or two to complete his/her toilet learning.” If the child continues to have problems, the policy states, the family may be asked to leave school. The policy is “firm,” according to the school.
The school also notes that its policy is based on “best practices.” But as a pediatric urologist, I can tell you it is not a good practice, let alone a “best” practice, to suspend 3- and 4-year-olds from school for failure to stay dry. Policies like these may sound reasonable,but they are based on a fundamental misunderstanding of toileting accidents.
Preschools tend to assume a child who has multiple accidents is not potty trained. This is a faulty assumption. In reality, most children who pee or poop in their pants have been trained for many months, if not years. The 4-year-old was trained two summers ago by a mom who put an immense amount of time and effort into the process.
Sending these kids home for a week to “work on” their potty skills is like sending dyslexic children home for a week to work on their reading. It’s going to fail, because their problems have nothing to do with lack of training.
Why Potty Trained Children Have Accidents
Why are these potty-trained children peeing in the yard and pooping on the rug? Because they are severely and chronically constipated and have lost control over their bladder and/or bowels as a result.
Here’s how it happens: For various reasons (often related to diet), pooping becomes painful for these kids, so they start to ignore the urge and withhold their poop. Stool then piles up in the rectum, an organ not designed as a storage facility, and the rectum stretches to accommodate the lump (think: rat in a snake’s belly). The hard mass of poop presses against and aggravates the bladder. The irritable bladder starts hiccupping and emptying without warning, before the child can possibly get to the toilet on time.
Meanwhile, the chronically stretched rectum begins to lose tone and sensation. And because these kids clench pooping muscles so often to keep the poop inside, these muscles become fatigued. In some kids these problems becomes so acute that poop just falls out of their bottom without the child even noticing.
Making matters worse, children who hold poop tend to hold pee as well. Several days this fall, the 4-year-old has held her pee from 8:30 a.m. to 4 p.m., despite sitting on the potty multiple times. This is some damaging behavior: Chronic pee holding thickens the bladder wall, making the bladder even more irritable and likely to hiccup.
All these problems can be reversed, with a regimen of enemas and laxatives to clean out the hard rectal clog and give the stretched rectum time to shrink back to size. Two weeks of at-home toileting instruction and M&M rewards won’t help.
The 4-year-old school’s toileting policy states that “a child’s willingness and cooperation is key.” The implication is that a child who sits on the toilet but won’t pee or who pees on the floor is uncooperative. Believe me, no child wants to have accidents at school. It is mortifying for them. Suggesting they are uncooperative and sending them home to attempt the impossible only adds to the shame they already feel.
Preschool Potty Deadlines Lead to Accidents
Ironically, the potty-training mandates that preschools deem “best practices” are often the very reason that children have accidents. When schools set September toilet training deadlines for 3-year-olds, they prompt many parents to start training their children at age 2 or 2 ½.
Problem is, most children are not truly ready at that age. Yes, toddlers are physically capable of using the toilet, but they lack the judgment to respond to their bodies’ signals in a timely manner. As a result, children trained as toddlers are much more likely to become habitual holders and are at higher risk for developing toileting problems down the road.
In fact, my published research shows that children trained before age 2 have triple the risk of later developing enuresis (daytime pee accidents) compared to children trained between ages 2 and 3. No, this doesn’t mean that training a 26-month-old is a good idea; it’s not. It just means that training a 23-month-old is an even riskier proposition.
Based on my clinical experience and research, I believe most children should be trained around age 3. This is not a hard-and-fast rule, but requiring 3-year-olds to be trained by September, while convenient for preschools, necessarily puts a large number of these children at high risk for developing problems in the ensuing years.
Even when 3-year-olds start preschool without any hint of constipation, they are vulnerable to developing the holding habit, because preschool potty-training mandates do not change a basic fact: Three-year-olds don’t like to poop or pee. They like to build towers and shop with toy grocery carts.
For kids who were trained before they were developmentally ready or who were constipated at the time they were trained (a common situation, due to our culture’s highly processed diet), the pressure to stay dry at school, without the safety net of a pull-up, only makes them more likely to hold pee and poop.
Think about it: You’re placing a 3-year-old in an unfamiliar environment where, for possibly the first time in her life, she has no family around for at least half the day. You’re expecting her to interrupt the teacher during the story circle and announce she needs to use the toilet or to climb out of the fort she’s just built with her friends and make her way over to the potty.
What happens is that the child doesn’t go, because she feels too inhibited or excited or worried that some other child will take her puzzle.
Preschool is prime time for children to become poop and pee holders. The holding habit can become deeply ingrained and have serious, lasting repercussions. Every day at my pediatric urology clinic, I treat school-age children, including tweens and teens, for bedwetting and daytime pee, poop accidents, and recurrent urinary tract infections. These problems are triggered by holding poop and exacerbated by holding pee. For most of my patients, preschool was when the troubles began.
The problems worsened when these kids began elementary school and were faced with restrictive bathroom policies or were rewarded for not using the bathroom.
Preschool teachers are in the position to make a positive and lasting impact on children by taking the following steps:
•Watching children closely for signs of constipation.
Contrary to popular opinion, frequency of pooping is not a reliable measure of constipation. Severely constipated children can poop multiple times a day, because they don’t fully evacuate.
Besides pee and poop accidents, the top two signs of constipation are XXL poops and poops that are formed, like pellets or logs. Children should be pooping piles of mush, like soft-serve ice cream or soft, thin snakes.
Other signs of constipation include urgent or frequent peeing, belly pain, an itchy anus, skid marks on underwear.
I recommend handing out our infographic, 12 Signs a Child is Constipated, to all parents and preschool teachers.
•Teaching children (and parents) to identify healthy poop
Children should be taught what healthy poop looks like. Yes, this is as important as learning how to zip up their jackets and get along with others! I recommend posting our How’s Your Poop? chart in the bathrooms of all preschools and sending the chart home with parents. Instruct children to look into the toilet after they poop — yes, gross, but helpful! — and to report to an adult if they are pooping pellets or logs.
Parents and teachers should glancing into the toilet bowl when possible.
•Teaching children what happens inside their bodies when they keep poop and pee inside
Preschoolers can understand the concept of poop piling up inside and forming a big, hard lump. They can understand the idea of a bladder being squished and hiccuping. Our book Bedwetting And Accidents Aren’t Your Fault contains illustrations that are helpful even for children who don’t have accidents.
•Providing a tall toilet stool and instructing children to plant their feet on the stool when they poop
Children cannot relax their pooping muscles when their feet are dangling. As pelvic-floor physical therapist Robin Lund, DPT, puts it, “Do you fully relax your body when you’re sitting on a barstool without a footrest to rest your feet on?” The answer is no.
The stool should be tall enough so the child is in a squatting position, as humans were designed to squat when pooping. Squatting straightens the rectum, allowing poop to fall out easily; by contrast, sitting upright is like trying to poop uphill.
Children also should be instructed to lean forward while pooping, elbows on knees, shoulders rounded. This position gives the child the benefit of gravity and stretches the abdominal cavity, allowing the colon more room to pump stool to the rectum for emptying.
•Encouraging boys to pee while sitting
As Robin explains: “Boys who stand when peeing usually tend to just their pelvis forward so they can dangle their penis over the toilet bowl and avoid dripping on the floor or toilet bowl rim.” As a result, they squeeze their butt cheeks and the muscles involved in releasing pee and may not be relaxed enough to fully empty.
•Providing children numerous opportunities to use the toilet throughout the day
For some children, the opportunity isn’t enough. They also need encouragement — and a good reason — to empty. I can’t offer blanket advice on how to get reluctant children to pee; different children respond to different approaches, but it is critical that children attempt to pee about every 2 hours. Openly discussing bathroom habits in school on a regular basis seems to help. It’s important for kids to know why they should never hold their pee, and why they need to poop daily. My own kids still like to tell me, ”I pooped today!”
•Allowing pull-ups and eliminating potty-training deadlines
I understand the arguments about preschool staffing issues. As one public preschool put it, “Lowering our student-to staff ratio to accommodate potty training would significantly reduce the number of children we can serve.”
But what kind of service are they giving to the children who do attend? Developmentally, preschoolers are a lot different from kindergarteners. Children who are newly potty trained need a lot of follow-up, including frequent reminders to use the toilet, no matter how well they’re able to stay dry. Schools argue that with their student-teacher ratios they can’t possibly give attention to toileting issues. My point exactly! They need to change the ratio or simply allow kids to wear pull-ups rather than enforce arbitrary rules on 3-year-olds.
Perhaps you are thinking: When will it end? We’ll have kindergarteners in diapers! But at some point, usually before their fourth birthday, all children are self-conscious about wearing pull-ups. Peer pressure almost always takes care of the issue. We don’t need school principals stepping in as enforcers.
And by the way, we do have kindergarteners in diapers. I see them in my clinic all the time. Most of them children who were trained early, typically to meet preschool deadlines.
Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and co-author, with Suzanne Schlosberg, of The M.O.P. Book: Anthology Edition and Bedwetting and Accidents Aren’t Your Fault.