By Steve Hodges, M.D.
It's not unusual for preschools to set potty-training deadlines and then issue ultimatums to parents when a child has persistent accidents.
For example, one mom emailed that her 4-year-old was given "one month to display fully potty-trained behaviors, or she will be dis-enrolled.”
This mom, who had diligently toilet trained her daughter, sent me her preschool's potty policy, which all parents were required to sign upon enrollment: "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 accidents persist, the policy states, the family may be asked to leave school. The policy was described as "firm.”
In another case, one of my patients was, at age 3 1/2, escorted off the premises of her preschool, along with her mom, after the girl had exceeded the school's allowance of 8 accidents in one month. The director told the girl's mom that her daughter had “had enough chances.”
Preschools like these describe their policies as “best practices.” But as a pediatric urologist, I consider toileting deadlines and ultimatums to be really unfortunate practices, based on a fundamental misunderstanding of potty training and toileting accidents.
What is convenient for preschools is not necessarily what is healthy for a young child's rectum or bladder. And what appears to be a sign of insufficient instruction or "learning" is actually a classic sign of chronic constipation.
As a result of school potty-training deadlines, even children who manage to stay accident-free throughout preschool develop may later develop problems, including enuresis (bedwetting and/or daytime wetting), encopresis (chronic poop accidents), and chronic urinary tract infections. But preschools don't see the repercussions of their policies, because the children affected have long since graduated.
Requiring preschoolers to be potty trained by age 3 sounds reasonable, as many children do quite well training around age 3. However, these "firm" policies prompt many parents to start training their children at age 2 or earlier. Parents want to make sure the skills are "locked in" well before school starts, lest they lose a spot in school.
Problem is, many children are not ready to train so young. Certainly, many 2-year-olds and even babies can be taught to pee and poop on the toilet. Social media is packed with video evidence of 6-month-olds and 6-week-olds using the potty But this is not the same thing as possessing the judgment to heed your body’s signals in a timely manner.
What matters most is the child’s ability to use the toilet when the urge strikes — not 2 hours or 12 hours later. Most babies and toddlers do not have that kind of maturity. Once they discover they can override the urge to pee or poop by clenching their toileting muscles, they do it all the time, and before long, it becomes habit.
Why is this such a bad habit?
Well, when a child repeatedly delays pooping, stool piles up in the rectum. Overtime, the mass dries out and hardens, so pooping becomes painful for the child, and the child works even harder at delaying poop. Meanwhile, the rectum becomes enlarged, to the point where it aggravates the bladder nerves.
At first, the child may experience urinary urgency, the desperate urge to pee RIGHT NOW, or urinary urgency, the incessant need to pee. If the constipation is not adequately treated, urgency and frequency develop into enuresis: wetting accidents. The aggravated nerves prompt the bladder to suddenly and forcefully contract, like a hiccup, and empty right then and there. The child has no chance of getting to the toilet on time.
Chronic pee holding makes matters worse by allowing the bladder wall to thicken and become more irritable and more likely to hiccup and empty.
In many children, the stretched rectum also loses tone and sensation. So, these kids don't even feel the urge to poop and are not able to fully evacuate. Also, because children clench their pooping muscles so often to keep the poop inside, these muscles become fatigued. Poop falls out of the child's bottom without the child even noticing.
Parents and preschools often use the term potty "refusal" and describe these kids as "stubborn" and "strong willed." In reality, they're experiencing the effects of a floppy rectum and tired pelvic floor muscles.
The fact that preschoolers are prone to delaying pooping and peeing is not surprising. Think about it: You’re placing young children in an unfamiliar environment where, for possibly the first time in their lives, they have no family around for at least half the day. They're expected to interrupt the teacher during the story circle and announce they need to use the toilet or to climb out of the fort they've just built with friends and make their way over to the toilet.
It takes maturity and confidence to do that. Instead, many preschoolers just don't go, because they feel inhibited or excited or worried some other child will take their puzzle.
This holding scenario is especially common among children toilet trained early, even if they were not pushed to do so. My published research shows that children trained before age 2 have triple the risk of later developing daytime wetting compared to children trained between ages 2 and 3. This doesn’t mean that training a 26-month-old is a good idea. It just means that training a 20-month-old is an even riskier proposition.
And "elimination communication," the practice of going diaper-free practically from birth, can backfire big time. I've had many EC parents join my private Facebook support group to resolve the enuresis and encopresis their children developed in preschool or later. Many of these parents are stunned that a child who was diaper-free and accident-free at age 1 needs to wear a pull-up at age 7.
Even for children who were trained at a totally appropriate age and have no constipation history, preschool is prime time for developing the holding habit. Young children don’t like to stop what they're doing to poop or pee! They like to build towers and shop with toy grocery carts. Plus, they are not taught the importance to responding to their body's signals asap. To the contrary, children are often told, "Could you just hold it a bit longer, until we're done with the lesson?" And they are praised for staying accident free rather than praised for responding to their body's signals right away.
At my clinic, I have a large caseload of teenagers with enuresis and/or recurrent urinary tract infections, conditions triggered by a holding habit they developed in preschool. The problems worsened when these kids began elementary school and were faced with restrictive bathroom policies or were rewarded for not using the bathroom.
Many parents are shocked when their kindergartners start having pee or poop accidents "out of the blue," and they assume the child has "regressed" in potty training. But the accidents are actually a sign that constipation that began in preschool has progressed. Since it happened gradually, and the signs are not well known, the parents were none the wiser.
Preschool potty deadlines are problematic enough, but enforcing these deadlines with ultimatums is even more misguided.
Preschools typically assume a child who has multiple accidents is "not fully potty trained." This is an erroneous assumption. Children who pee or poop in their pants are fully potty trained. It's just that their signals to pee and poop have gone haywire due to chronic constipation.
Sending a child home for two weeks to “work on” their potty skills is like sending a dyslexic children home to "work on" their reading. It’s going to fail, because their problems have nothing to do with lack of instruction. No amount of "training" will dislodged the hard mass of poop clogging their rectum. (What will? A treatment regimen that combines laxatives and enemas.)
The preschool potty policy I mentioned earlier 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 these kids are uncooperative and sending them home to attempt the impossible only adds to the shame they already feel.
Here's how preschool teachers can make a positive and lasting impact on children in the area toileting:
•Watch 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 suggest handing out our free infographic, 12 Signs a Child is Constipated, to parents and preschool teachers, so they can identify a problem early and nip it in the bud. I spell out a treatment regimen in The Pre-M.O.P. Plan: How to Resolve Constipation in Babies and Toddlers and Overcome Potty Training Struggles.
•Teach 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 preschool bathrooms and sending the chart home with parents. Instruct children to look into the toilet after they poop — gross, but helpful! — and to report to an adult if they are pooping pellets or logs. Parents and teachers should glance into the toilet bowl when possible.
•Teach 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 the rectum stretching, the way a snake's belly stretches if it eats a rat for lunch! Preschoolers can understand the idea of a bladder being squished by an enlarged rectum and hiccuping.
•Provide a tall toilet stool and instruct children to plant their feet on the stool when they poop.
Children cannot relax their pooping muscles when their feet are dangling. Think about it: Do you fully relax your body when you’re sitting on a barstool without a footrest to rest your feet on? Nope.
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.
•Encourage boys to pee while sitting.
Preschool boys who stand when peeing tend to jut their pelvis forward, so they can dangle their penis over the toilet bowl and avoid dripping on toilet bowl rim. As a result, they squeeze their butt cheeks and the muscles involved in releasing pee, and they may not be relaxed enough to fully empty.
•Provide 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 is a good idea.
•Allow pull-ups and eliminate potty-training deadlines.
I understand the arguments about preschool staffing issues. “Lowering our student-to staff ratio to accommodate potty training would significantly reduce the number of children we can serve," one public preschool asserted.
But what kind of service are they giving to the children who do attend? Developmentally, preschoolers are a lot different from kindergartners. Children who are newly potty trained need a lot of follow-up, including frequent reminders to use the toilet. It makes more sense to allow kids to wear pull-ups rather than enforce arbitrary rules on 3-year-olds.
Perhaps you are thinking: When will it end? If we don't enforce potty deadlines, we’ll have kindergartners in diapers!
But at some point, usually by age 4, children become self-conscious about wearing pull-ups and naturally want to use the toilet. We don’t need school directors stepping in as enforcers.
And the children who struggle to potty train or have accidents? Well, those kids need treatment for chronic constipation, not threats.
And by the way, we do have kindergartners in diapers. I see them in my clinic all the time. Most of them are kids who were potty trained too early, typically to meet preschool deadlines.