By Steve Hodges, M.D.
Usually I ignore potty-training articles I disagree with, but sometimes an “expert” promotes ideas so outrageous — so harmful to children and parents — that I feel compelled to respond.
Such is the case with psychologist John Rosemond’s recent article, “Potty-training should be complete by 30 months.”
Not only is Rosemond wrong about that, but his advice, if heeded, will put children at elevated risk for chronic constipation, enuresis (bedwetting and daytime pee accidents), and encopresis (poop accidents) — conditions I treat every day.
I wish he’d stop the moralizing and get a grip on how the human body works.
Rosemond’s article was prompted by Kristen Bell’s revelation that her 5-year-old daughter, Delta, still wears diapers at night. Bell said she’s not worried and considers bedwetting “pretty normal for a 5 yr old whose tiny bladder can’t take the 10 hr challenge yet."
In a blog post, I explained that while Bell’s underdeveloped-bladder theory sounds reasonable, and while I totally sympathize with the sentiment behind it (and am a huge fan of Bell!), the theory is actually not born out by science.
When it comes to bedwetting, lots of folks confuse “common” with “normal.” In reality, enuresis, while exceedingly common among 5-year-olds, is almost always caused by chronic constipation. When kids delay pooping, as they so often do, stool piles up in the rectum; eventually the rectum stretches to the point where it encroaches upon and aggravates the bladder nerves. The child’s bladder hiccups and empties without warning.
I urged Bell to have her daughter’s abdomen x-rayed and rectal diameter measured, to confirm (or rule out) that’s what is going on with Delta.
Rosemond, however, sides with the Twitter trolls, describing Bell as “too lazy to toilet train her child.”
This is nonsense. Children who wet the bed at age 5 are toilet trained; they are also constipated and therefore have unstable bladders.
Bedwetting should never be mistaken for parental “laziness” or a child’s failure to grasp toilet training. Neither should daytime accidents, though it happens all the time. Many of my patients have been suspended from preschool or elementary school for having accidents and have been sent home to “work on” toilet training, on the theory that they just haven’t mastered the concept.
That’s like sending a dyslexic child home to “work on” reading for a few weeks! In both cases, insufficient training has nothing to do with it.
What really drives Rosemond bonkers is Bell’s notion that every child is different and should be afforded the time to develop accordingly. He bemoans “parenting relativism, which begets the notion that the raising of a child should be tailored to the ‘individual needs’ of said child.”
In Rosemond’s world, no child should reach the age of 2 ½ and still wear diapers. He rants thusly:
It is an insult to the intelligence of a human being to allow said being to soil and wet herself past age 30 months, which is my most liberal limit. A dog can be trained to eliminate only in the back yard before he’s 6 months, the human equivalent of which is between 18 and 30 months. It is disgraceful to expect less of a human than one would expect of a dog.
First off, toilet training has nothing to do with intelligence. It’s about maturity. My published research has found that children trained before age 2 face triple the risk of developing chronic constipation and daytime enuresis (wetting) as children trained between ages 2 and 3.
This does not mean that training at 25 months is A-OK. It just means children trained earlier face worse odds. Based on all my research and experience, I advise parents to start training around age 3, give or take. In this case, children’s individual needs should for sure drive the timeline!
There is no doubt toddlers, and even babies, can be trained to pee and poop on the toilet. The problem is, they don’t possess the maturity and good judgment to heed 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.
I write about this at great length in The Pre-M.O.P. Plan: How to Resolve Constipation in Babies and Toddlers and Overcome Potty Training Struggles.
I hesitate to delve into Rosemond’s inane comparison between humans and dogs, but I will say this: Humans, especially those of us living in the 21st century, are uniquely primed to become constipated. It’s because we are smart — too smart for our own good.
It would never occur to a dog or a cat or a hamster to withhold poop for days. Animals other than humans go when they need to, unencumbered by society’s concept of decency, undistracted by iPads or classroom story circles, unpressured by preschool potty-training deadlines.
But today’s humans constantly postpone pooping. If we’re not near a toilet when we get the signal or if we’re engrossed in something else, we tend to override the signal by tensing our pelvic floor muscles and anal sphincter. Humans can delay pooping for hours, even days. Human children are masters of delay.
I don’t think Rosemond has ever considered this. His advice to Bell on bedwetting suggests he has no idea enuresis is caused by constipation rather than parental inadequacy.
If you want your daughter to stop wetting the bed, do not put diapers on her at bedtime.
The feel of bulky fabric around the pelvic area is associated with spontaneous release. Diapers and pull-ups at night extend bedwetting indefinitely. To achieve night dryness, a child must wet the bed, not a diaper.
This is false. It’s not “bulky fabric” that is associated with accidents; it is an unstable bladder.
Rosemond claims that to stay dry, children “must experience the sensation of wetness,” a theory I debunk in “Nighttime Potty Training is Not a Thing.” (If that approach worked, I'd have few patients; pretty much every family has tried that at one point , along with the doomed middle-of-the-night-wake-up strategy.)
Rosemond advises parents to put bedwetting children to sleep with a fluffy towel or two underneath them and instructions not to wake up Mom and Dad — and to top it off with a bit of shaming:
“Here are more towels. Use them if you must,” he advises parents to tell their kids.
Rosemond seems to have no clue that shaming children does not resolve bedwetting! A child's bladder cannot be humiliated into ceasing to spasm. What does work is resolving the rectal clog, so the child's rectum can shrink back to size and stop bothering the bladder.
It’s attitudes like Rosemond’s that prompted me to write Bedwetting And Accidents Aren’t Your Fault, a children’s book that Rosemond would surely pan!
As a last resort, Rosemond recommends a bedwetting alarm, adding that “bedwetters, generally, sleep very deeply.” As I explain here, bedwetting children actually do not sleep more deeply than children who stay dry overnight; the “deep sleep” theory is entirely unsupported and makes no sense, anyway.
For some kids, alarms can be helpful, but only in conjunction with a serious program to resolve chronic constipation, such as the Modified O’Regan Protocol. Alarms don’t get to root of the problem.
Commentary such as Rosemond’s only serves to make parents feel stressed and guilty. That may well be his goal, but in the end, it’s the children who get hurt.