Three more children with toileting difficulties are dead. It turns out that AJ Freund, the Illinois 5-year-old reported missing by his parents, was actually bludgeoned by them and forced to take a 20-minute cold shower after he lied about soiling his underwear. His body was found wrapped in plastic and buried in a shallow grave, a month after his mom was heard on video berating the boy for wetting his bed.
And this week an Alabama man has been indicted for capital murder after allegedly killing his girlfriend's 2-year-old because the boy wouldn't potty train. According to the autopsy, the toddler suffered brain hemorrhaging and a lacerated kidney, and his stomach was separated from his small intestines.
This news follows a report by the Mesquite, Texas, police chief that a toddler had been beaten to death by her mom's boyfriend "because of her lack of potty training." As a pediatric urologist specializing in enuresis (wetting) and encopresis (stool accidents), I’ve collected stories like this for years — children beaten, scalded, and otherwise abused and humiliated as punishment for toileting accidents. In March I presented a poster on this topic at a urology conference. To me, these stories represent the extreme end of what I encounter daily: a misunderstanding — among parents, schools, and even physicians — of 1.) what actually causes enuresis and encopresis and 2.) when children are ready to toilet train. Now, I realize the parents suspected of these murders have problems that go way beyond a lack of education about toileting. AJ Freund, for example, was reportedly born with opiates in his system; his parents were particularly ill-equipped to handle, let alone medically treat, their son’s accidents. But even among patient and conscientious parents, blame and frustration surface — in subtle ways that adults don’t recognize but children internalize. What I explain to these folks: accidents are never a child’s fault. Enuresis and encopresis are medical conditions, straight up, not symptoms of "laziness,” “acting out,” or “attention seeking.” I hear these phrases from parents regularly, sometimes while their child sits silently in my exam room, head hanging. In reality, virtually all accidents in toilet-trained children are caused by chronic constipation, a condition easily and often missed by parents and doctors. And when a child struggles to potty train, it's either because the child is not mature enough to train, is chronically constipated, or both.
Most toddlers fall into the category of "not ready." As my published research indicates, children toileted trained before age 2 have triple the risk of developing chronic constipation and daytime enuresis. This is because toddlers, while capable of peeing and pooping on the toilet, generally do not possess the judgment to respond to their bodies' urges in a timely manner.
In addition, a good number of children are already constipated by age 2, which makes toilet training an exercise in futility and frustration for parent and child alike. But our culture is so eager for children to be toilet trained, with preschools setting inflexible potty-training deadlines, that many parents feel compelled to train their toddlers. In turn, they impart unrealistic expectations on their children — and, on occasion, murder them.
How does constipation lead to accidents?
When kids delay pooping, as they do for various reasons, stool piles up in the rectum and, over time, can form a large mass. Eventually, the rectum stretches enough to encroach upon and aggravate the bladder, which empties abruptly and without warning, day or night. In the case of encopresis, the stretched rectum loses its tone (the way a stretched-out sock loses its elasticity) as well as its sensation, so stool just drops out of the child’s bottom. It’s a vicious cycle: Kids with encopresis cannot feel the urge to poop or hold in stool, so even more poop piles up and falls out. Parents find it hard to believe a 5-year-old or 10-year-old could soil his underwear without noticing, but it’s a common occurrence and easily explained. (In rare cases, accidents might be the sign of a missed spinal cord or urinary-tract abnormality, but I cannot emphasize how rare these cases are. And contrary to popular opinion, bedwetting is not caused by deep sleep, an “underdeveloped” bladder, or a hormonal imbalance.) Frustrated parents insist their child is “old enough to know better” and they’ve “tried everything” to motivate the child to stay dry — candy, iPad time, punishments. But these approaches fail for good reason: a bladder gone haywire won’t respond to the promise of M&Ms or the threat of a cold shower. These kids cannot control their bladders and bowels, no matter what. They need medical treatment to clean out the rectum on a daily basis, so it can shrink back to size and stop aggravating the bladder. Yet these kids are often blamed and shamed, at home and school. Many of my patients have been threatened with school suspension for “excessive” accidents and referred to psychologists for what is clearly a physiological issue. Schools routinely restrict restroom access, assuming kids who frequently ask to use the restroom want to goof off in the hallways. In reality, urinary frequency and urgency are symptoms of chronic constipation. Restroom restrictions exacerbate toileting troubles, teaching kids to ignore their body’s urges and signaling that adults do not trust them. In a University of California at San Francisco study, 88% of elementary teachers reported asking children to hold their pee; 36% reported rewarding students who didn’t use restroom passes or punishing those who did. The lead author, a teacher-turned-doctor, had taught second grade at a Bronx school with strict restroom policies. “I noticed kids having accidents in the classroom,” she told me. “It’s just a horrifying experience for a kid.” Schools are not above humiliating students for toileting difficulties. Administrators at a Texas school, after finding stool on the gym floor, forced fifth-graders to lower their pants for a “poop inspection." A Virginia preschool principal escorted a 3-year-old and her mom off the premises, insisting the girl had had “enough chances” to master potty training. That girl became my patient, and an X-ray of her abdomen showed why she was having accidents: her rectum, stretched by a stool mass the size of a Nerf basketball, was squishing her bladder. Notably, a physician had examined her belly, reported “no masses palpable,” and recommended no further evaluation or treatment. Given how often constipation is overlooked by physicians, it’s unsurprising that most of my patients’ parents didn’t know their child was constipated, let alone severely so. Constipation is often defined as “infrequent pooping,” but many constipated children poop daily, or more often. They just don’t fully empty. More telling signs of constipation, besides accidents, are extra-large stools and stools shaped like rabbit pellets or hard logs. I can usually persuade parents their child has a medical condition by presenting the child’s abdominal X-ray. Often the rectum is stretched to 6 cm or greater, twice the normal diameter. As one mom told me, “Until you actually look at the film, it’s hard to understand. My 7-year-old was so stuffed with poop that his bladder was basically flattened. I could see why pee couldn’t stay in there all night.” Another mom said: “Seeing the X-ray really decreased our frustration with our 5-year-old son.” She stopped rewarding her son for dry underwear, and the boy stopped hiding his wet pants. “Now he doesn't have to feel disappointment for not earning a reward,” she added. Yes, some children with encopresis and/or enuresis have behavior issues. But it’s typically the accidents that cause the behavior, not the other way around. When you can’t control your bladder or bowels and the adults in your life blame (or abuse) you for it, you’re going to react. Even subtle parental displays of blame — eye rolls or sighs of disappointment after an accident — can wound kids. Ironically, the parents most intolerant of accidents are often those who pushed their children to train before they were ready, thereby making their child more prone to accidents. With aggressive treatment (I advocate the Modified O'Regan Protocol, a regimen that combines enemas and laxatives), encopresis and enuresis will resolve, with time. But kids who are blamed rarely receive appropriate treatment. At best, they’re given bladder medication, which does nothing to resolve constipation and can actually exacerbate it. I have many teenage patients; their constipation was overlooked for years. Many have been blamed — told they’d stop bedwetting if they’d just get more sleep, avoid caffeine, and stop stressing out. One teenager emailed me: “I’ve done special diets, alarms, being woken up at all hours by my parents, limiting drinks after dinner, and [medication] for a year. My doctor isn’t the kindest person and says I should just ‘get off’ my medication. If only he knew how hard it is.” The problem is never a lack of effort; it’s a stretched rectum and aggravated bladder. This message may never reach parents like AJ Freund’s. But if more adults understood why accidents happen, more kids would receive treatment and compassion rather than anger, disappointment, or abuse. Steve Hodges is a an associate professor of pediatric urology at Wake Forest University School of Medicine and co-author of Bedwetting and Accidents Aren’t Your Fault and other children’s books.