By Steve Hodges, M.D.
At the start of every school year, Google alerts me to articles like this one: Teachers Are Seeing More Kindergartners Arrive at School Still in Diapers.
A handful of teachers report that a handful of their students wear pull-ups to school, a “concerning education trend” is declared, and blame is assigned.
The 2023 version, published by We Are Teachers and “informed” by over 1,000 Reddit commenters, offers three explanations: lazy or ignorant parents, lax preschools, and super-absorbent diapers.
As a pediatric urologist — a doctor with many school-age patients in pull-ups — I call tell you all three explanations are way off base.
Also, this “trend” is not new and is not even a trend. Though the article proclaims kindergartners are “all of a sudden” wearing pull-ups to school, in fact enuresis (chronic wetting accidents) and encopresis (chronic poop accidents) have been common among 5-year-olds for decades.
“Kindergartners in diapers” is old news, and so is the fact that accidents are “happening everywhere.”
Heck, back in 2014, I blogged on this very topic after a U.S. newspaper published “Students who aren’t potty trained an issue for kindergarten teachers” (sound familiar?) and a UK outlet reported that staff are “fed up” with “potty training accidents.”
A decade later, nothing has changed. Teachers still lack training on the actual causes of accidents, parents are still shouldering blame, and many children still lack the treatment and support they need.
(Well, one change is that my website now offers several free resources for school personnel, including teachers, school nurses, and mental health counselors.)
Let’s start with the erroneous premise of these articles: that kindergartners "arriving at school without being potty trained.”
I guarantee these kids are potty trained. Accidents have nothing to do with a lack of “training.” In reality, pee and poop accidents have a medical cause: an enlarged rectum, due to chronic constipation. X-ray any of these kindergartners in diapers and you'll see a rectum more than twice the normal diameter of 3 cm.
When children delay pooping, as they often do, stool piles up in the rectum, and the rectum stretches to accommodate the hardened mass. In some kids, the enlarged rectum aggravates the nearby bladder nerves, causing the bladder to contract randomly and forcefully and to empty without warning. These contractions are like hiccups: you can’t stop them.
In other kids, the stretched rectum loses so much sensation and tone that the child cannot feel the urge to poop and can’t fully evacuate. So, even more stool piles up, stretching the rectum further. Stool just drops out of their floppy rectum, without the child noticing.
Many children have both enuresis and encopresis.
There is but one way to resolve these conditions: clean out the rectum and keep it clear for several months. This allows the rectum to shrink back to its normal size, regain tone and sensation, and stop bothering the bladder nerves.
Unfortunately, chronic constipation in children often goes unrecognized or inadequately treated for years. Physicians often dismiss accidents as “normal” and assure families the child will outgrow the issue.
That’s how you end up with kindergartners, even fourth-graders, in pull-ups, a devastating and stressful scenario for kids and parents alike (and apparently an annoyance for some teachers).
In the early stages of treatment, my patients have no choice but to wear pull-ups to school. After a month or two of a regimen such as the Modified O'Regan Protocol (M.O.P.), daytime accidents typically cease, though treatment takes longer if the child started with both poop and pee accidents.
Most children with daytime accidents also experience bedwetting, a symptom that takes longer to clear up, so school-age kids who no longer need daytime pull-ups may still be wearing them at night.
Now, let’s consider the three explanations offered by the We Are Teachers article.
Explanation #1: “Parents not understanding potty training”
In reality, it’s the Reddit commenters who don’t understand potty training. Fact: no amount of “training” will dislodge the hardened mass of stool at the root of pee and poop accidents. A dilated rectum will not respond to instruction, no matter how thorough.
Yet, teachers suspect parents of students in pull-ups "started teaching toilet training but didn’t teach it to mastery.”
My oldest daughter recently got her driver’s license. You know what requires instruction to mastery? Parallel parking! Merging onto the interstate!
But not potty training. When a child is mature enough to use the toilet and free of constipation, toilet training should go smoothly, without massive amounts of instruction.
The child simply needs to feel the urge to pee or poop, understand the importance of acting on that urge immediately, and be able to remove their pants and sit on the toilet.
If a child is struggling, the child is likely too immature to use the toilet or has a clogged rectum, or both.
Attempting to further “train” a kindergartner with enuresis or encopresis is like trying to train a blind child to see.
Enuresis and encopresis happen to be highly treatable — but with laxatives and enemas, not lectures and sticker charts (and certainly not with punishment).
Even more off base are comments assuming that parents of 5-year-olds in parents are lazy and that smart kids should not have accidents.
One teacher posted on Reddit: “I had a 2nd grade girl this year in diapers in my class (no IEP or delays). Dad would get pissed that other kids were teasing his 'perfect angel' but never thought to fix the problem and potty train her. Smartest kid in class, but just never had parents who bothered to teach her.”
Comments like these are cruel and ill-informed. Intelligence has no bearing on enuresis or encopresis. I assure you parents of 7-year-olds in diapers feel despair. I talk to these folks all day in my clinic and in my private support groups.
Among the Reddit commenters was a mom pleading for teachers to show her daughter compassion:
“We have been through the RINGER trying to get her potty trained. She has been to the GI doc, urologist, pelvic floor therapy and now occupational therapy. We have done everything we can possibly think of to help her. She is devastated by it. She doesn’t want to have accidents. We are devastated for her. Just get some more context before judging too harshly.”
That post could have been written by hundreds of parents I know.
Explanation #2: “Schools not being firm enough on toilet training as a prerequisite.”
Actually, the opposite is true. Too many preschools require potty training by age 3, with damaging repercussions.
Strict potty deadlines and policies prompt many parents to train their children before the child is ready, dramatically increasing the child’s risk of developing chronic constipation, enuresis, and encopresis.
Sure, you can train babies and toddlers to use the toilet. Parents do it all the time and boast about it on social media. But pooping and peeing on the potty is not the same thing as possessing the judgment to respond to your body’s urges in a timely manner. The difference is critical.
Many newly trained children develop chronic constipation while in preschool. Yet it can take years for constipation to reach critical mass, so to speak, and start wreaking havoc on the bladder.
Many “successfully” trained preschoolers don’t start having accidents until kindergarten, so preschools with potty-training deadlines don’t witness the harmful consequences of their policies.
Other kids struggle with toilet training immediately because they were constipated when training began, in many cases from infancy. Attempting to train a child with a clogged rectum is futile and frustrating for parents and child alike. Accidents are inevitable.
Many preschools treat kids with enuresis and encopresis quite harshly.
One commenter to the We Are Teachers article posted, “My preschool would kick kids out who weren’t potty trained and didn’t have an IEP.” She seemed to be in agreement with the policy.
Another teacher, implying that schools today are too lax, posted: “When I started teaching, kids couldn't come to kinder unless they were potty trained. And now we have 7-year-olds in diapers.”
The mom of one of my patients showed me her preschool’s policy: “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 toilet learning. If accidents persist, families may be asked to leave school.”
Sadly, many schools make good on this threat, not understanding these kids are “fully toilet trained” but have a treatable medical condition.
Explanation #3: “The diapers themselves”
I’ve heard this theory a million times: Today’s super absorbent diapers make it so “comfortable’ to stay wet that kids lack incentive to use the toilet parents lack incentive to potty train.
One commenter posted: “If [children] still wore old-fashioned terry-towelling nappies, they would soon notice how heavy, cold, wet, stinky and horribly soggy they were, and, if parents had to wash and dry these, rather than just being able to chuck disposables away, they might be more motivated to address the problem.”
Sure, today’s super-absorbent diapers are more comfortable than those old soggy ones from my childhood. But among kids with encopresis and enuresis, the real problem is their signals to poop and pee have gone haywire.
The urges to pee and poop come via the rectum, the bladder, and the brain — not the diaper.
I’m not surprised teachers have the wrong idea about kindergartners in diapers After all, they’re not trained on bladder and bowel dysfunction, and even many physicians urge families to “wait it out” rather than treat enuresis and encopresis early and aggressively.
As a result, school-age children in pull-ups, along with their parents, are blamed and shamed, in person and online.
One teacher posted: “There are FOUR kids in my [first-grade] class who are not potty trained. They pee and poop in their diaper or pull-up, then go to the nurse to be changed. One of them is 7 years old, the others are all 6. It's insane.”
Another posted about a pull-up discovered in the trash in a second-grade classroom, as if the discovery itself was a horror. Just imagine what it felt like to be the second-grader who discreetly put it there.