By Steve Hodges, M.D.
“I wiped poop on my son's face tonight. I don’t feel bad either.”
That apparently is how one Oklahoma mom handled (literally) her 4-year-old’s latest poop accident, in an incident she posted on Facebook.
The backlash was so harsh that she closed her Facebook account. I’m glad her post provoked outrage, but in truth, this is just an extreme version of a scenario that plays out all the time: children getting blamed for accidents.
In my decade treating children with enuresis (pee accidents) and encopresis (poop accidents), I’ve seen kids shamed by their parents right in my exam room. “He’s just being lazy” or “She’s old enough to know better” or “He’s doing it for attention. There’s no way a 10-year-old could poop in his pants and not notice.”
But there is!
If you read past the Oklahoma mom’s shocking first sentence, you will see the frustration and lack of knowledge I encounter daily in my clinic. “It’s like he doesn’t care to poop in his pants,” the mom writes. “It literally DOESN’T BOTHER HIM.”
I know it seems impossible a child could not appear to care that he is sitting in poop, but this is easily explained: The accidents don’t bother this child because he cannot feel them. His rectum has lost sensation, and he does not notice when poop falls out.
Encopresis is caused by chronic, severe constipation. When children regularly delay pooping (usually because it’s painful), stool piles up in and stretches the rectum. A stretched-out rectum is like a stretched-out elastic waistband: It loses springiness. The floppy rectum can’t squeeze down to expel the entire load of poop, so some of it remains in the rectum. Because the intestinal walls have lost tone — and because the child's pooping muscles fatigue from all that clenching — some of the poop just drops out.
A stretched rectum also loses sensation, so the child doesn’t feel the urge to poop. This lack of sensation drives a vicious cycle: Even more poop piles up, further stretching the rectum and compromising its tone and sensation. More poop falls out.
One mom told me she’d find “hard little rabbit pellets” all over her house when she would vacuum. This is not uncommon.
Many children with encopresis also have daytime or nighttime pee accidents; I’ll bet that Oklahoma mom’s son wets his bed. That’s because the stretched rectum presses against the bladder, causing the nerves that control the bladder to go haywire. The bladder hiccups and empties without notice.
The poop-stuffed rectum also squishes the bladder aside. If you’ve been pregnant (and, admittedly, I haven’t, but my wife has given me the play-by-play), you know what it’s like to have your bladder encroached upon: You have to pee more often and more urgently. What if, instead of a baby, a solid, grapefruit-sized mass of poop was pressing on your bladder? Same effect.
I see these large masses all the time because I X-ray my patients, in part to show parents there’s a medical explanation for the accidents. The mom who was vacuuming up poop told me: “Until you actually look at the film, it’s hard to understand. I was blown away. My son was so stuffed with poop that his bladder was basically flattened.”
Prior to this, the mom did not even know her son was constipated, because he pooped daily. The fact is, many severely constipated children poop every day — even multiple times a day. They just don’t fully empty. Some softer, fresh poop oozes around the hard clog stretching the rectum, so nobody is the wiser.
For some parents, even an X-ray won’t convince them that their child is blameless. This week I heard from a mom whose child has a long history of constipation. An X-ray ordered by her GI doctor showed a severe back-up, and this mom wisely gave her daughter enemas to clear out the rectum. The accidents stopped. But then they returned, as they will if you stop treatment too soon. The woman wrote:
“I'm not 100% convinced this isn't just laziness/attention. In the last 12 months we have moved to a new house in a new town and we've had another baby. She's expressed a lot of jealousy regarding my time with the baby. I try my hardest to give her one-on-one time and do special things with her, and it doesn't make a difference. More recently she's been complaining of tummy aches, but she does seem to mention them at really ‘convenient’ times.”
You literally can’t find a clearer case of constipation than this child. And yet this mom can’t let go of the “laziness/attention” notion.
Let me be clear: Accidents are never caused by laziness or attention seeking. Or stress or bullying or other psychological issues.
Furthermore, accidents have nothing to do with inadequate potty training. The Oklahoma mom posted on Facebook: “I always reward him with candy any time he manages to poop in the potty. But it’s like that doesn’t matter either. He is completely potty trained. Why is pooping so hard? We have been working on this for months.”
Why is pooping so hard for this kid? Because it hurts to pass giant, hard stools, and because he has lost control of his pooping muscles. Mystery solved.
Rewarding a child for pooping in the toilet is like rewarding a child with eczema on days he has clear skin. Fruitless! (For a better approach to potty training, read our guide "7 Super Important Rules for Potty Training Success: A Guide for Parents.")
The accidents won’t stop until a child’s rectum is thoroughly cleaned out and remains clear for many months, ideally with an enema regimen such as the Modified O'Regan Protocol. Only then will his stretched rectum shrink back to size and regain tone and sensation.
I’ve explained this in countless letters to schools, on behalf of students suspended for having accidents. The schools maintain they are just giving the child “more time for potty learning.” But all the time and M&Ms in the world won’t clean out a clogged rectum.
It’s not just preschools that shame kids for having accidents; elementary schools do it, too. I wrote about a Texas school that asked fifth-graders to pull down their pants for a “poop inspection"; they were trying to determine which kid pooped on the gym floor. Ironically, restrictive school bathroom policies contribute to the constipation that is responsible for these accidents.
Unsurprisingly, potty training is one of the most common triggers for child abuse. I have a Google alert set for “potty training” and frequently read news reports of school-age children scalded, beaten, or humiliated for having accidents. A Florida mom, fed up with her 10-year-old’s bedwetting, forced the boy to parade around in a princess gown — and then posted the pictures on Facebook. A Maui woman was sentenced to 3 months in prison for abusing a child enrolled in her potty bootcamp.
But you don’t have to hit a kid or smear poop on his face to humiliate your child. You don’t even need to call the child “lazy.” Groaning when you have to change sheets or clean dirty underwear is enough to signal to your child that she’s at fault. I know it can be hard to keep your cool in the face of repeated accidents. But kids internalize the blame, which is why I wrote Bedwetting and Accidents Aren’t Your Fault. That is the message kids need to hear.
These kids feel crummy enough that they are not in control of their bladder and bowels. They get teased by peers and avoid sleepovers and camp. The last thing they need is their parents — and doctors — piling on.
Sadly, many physicians reinforce the mythology that children are to blame for bedwetting and accidents. As one mom in my Facebook support group recently posted: “My pediatrician said the problem is a control issue, and he'll stop having accidents when he is ready." Another mom posted: “Our doctors told me our daughter was struggling with mental issues, that she was lazy.” Yet another mom: “The first pediatrician we saw said my daughter was doing it on purpose for attention.”
I can't really expect parents to understand the root cause of accidents if their doctors are not providing them with accurate information.
Many of my patients have been referred by pediatricians or schools to behavioral therapists. But therapy, like candy, won’t fix the problem. Constipation must be treated aggressively.
So yes, the Oklahoma mom abused her child, and it’s outrageous. But I hope this extreme incident won’t obscure the more common and pervasive problem I see daily.
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 Bedwetting and Accidents Aren't Your Fault, Jane and the Giant Poop, and The M.O.P. Book: A Guide to the Only Proven Way to STOP Bedwetting and Accidents.