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Why Threats and Bribes Won't Stop Bedwetting (And What Will)

By Steve Hodges, M.D.

News broke last week that two Florida cops had handcuffed and jailed their sobbing 3-year-old son to teach him "the consequences" of pooping in his pants.

When the couple learned their conduct was being investigated, they were outraged.

“I know we didn’t do anything wrong,” the boy’s mom, a detective sergeant, said, according to body-cam footage. She called the investigation “the definition of insanity.”

Of course, the actual definition of insanity is hauling a 3-year-old to jail — and, more broadly, punishing, shaming, or blaming a child for toileting accidents.

But it happens all the time. The Florida case made headlines because the punishment was off the charts, but countless kids with encopresis (chronic poop accidents) and/or enuresis (daytime wetting or bedwetting) are subjected to “discipline” and humiliation.

Just this week I received two emails from teens who have been punished for bedwetting and were seeking guidance on enuresis treatment.

A 19-year-old wrote: "All my life I've been beaten or shamed, and I don't know what to do. I can't even speak with my parents about this issue. They won't hear of it. Please help me."

A 15-year-old honor student and athlete wrote: "My dad screams about how I’m not a little kid anymore. He wants me to sleep in a wet mattress to learn what ‘discomfort is’ and how disgusting I am that I pee myself still. He has tried punishments like taking away my electronics and my breakfast."

Sometimes parental rage escalates to the point where parents kill their children.

Two days ago, a Nigerian man was arrested for killing his 6-year-old boy over bedwetting. Think this would never happen in the United States? Think again! Recently, a New York woman was convicted of murdering an 8-year-old boy, her fiance's son, who froze to death in the garage where she'd banished him due to his bedwetting. Here, I discuss similar cases in Alabama, Texas, and Illinois.

What's especially tragic is that kids who are shamed for bedwetting come to believe they are at fault. The 15-year-old who emailed me wrote, "It just makes me so mad at myself that I can’t outgrow it."

In reality, he and kids like him are victims of a culture that perceives accidents as behavioral and/or psychological issues that require discipline or counseling, rather than what accidents actually are: the treatable symptoms of chronic constipation. Punishing a child for accidents is no different from inflicting punishment for ear infections or asthma. Who would be OK with that?

In his email, the 15-year-old said his accidents make him feel “trapped in my own body and make me feel like I don’t have control.”

He’s right: He doesn’t have control. With enuresis, the stretched rectum encroaches upon the nearby bladder, aggravating the bladder nerves. As a result, the bladder “hiccups” randomly and forcefully, emptying without warning. There’s no way this kid can wake up and sprint to the toilet in time to prevent an accident.

Similarly, the jailed 3-year-old can’t stop the poop from falling out of his bottom. When a child has encopresis, the clogged rectum stretches to the point of losing tone and sensation. Kids don’t feel the urge to poop and can’t fully evacuate, so more stool piles up. Eventually, the overflow just drops out, without the child even noticing.

Taking away a child’s electronics or putting him in jail will not prevent either scenario. A stretched rectum simply will not respond to threats or punishment. (Neither will it respond to sticker charts or praise.)

However, a stretched rectum will respond to treatment. When the rectum is unclogged and fully evacuated on a daily basis, this organ will shrink back to size, regain tone and sensation, and stop bothering the bladder. That’s when accidents stop.

Any parent skeptical their child is constipated can simply have their doctor order an abdominal x-ray. You can see the clogged rectum plain as day. Anyone skeptical that resolving constipation stops accidents can read all the research proving it. (An enema-based regimen such as the Modified O’Regan Protocol, aka M.O.P. will accomplish this far more effectively than oral laxatives such as Miralax.)

So, where do folks get the idea that accidents are caused by willful behavior or laziness?

This notion is so pervasive in popular culture that “bedwetting” has become political shorthand for whining. But I am sorry to say that some ill-informed healthcare professionals perpetuate this notion as well.

The 15-year-old said his doctor told him, “You’ll outgrow the accidents when you’re ready,” offering him no other explanation for his bedwetting and no treatment. As if staying dry overnight was a matter of wanting it badly enough! Several of my patients have heard this nonsense from other doctors.

Along these warped lines, a mom in our private enuresis/encopresis support group last week posted a galling chart provided by her child’s occupational therapist in Australia. The chart spelled out two paths for the child: the “good choice” and the “bad choice.”

The “good choice” is to “wee in toilet,” which leads to “happy parents” and a “prize.” The “bad choice” is to “wee in undies,” which leads to a “sad/disappointed parent” and the consequence to “clean your own undies.”

It’s not just individual healthcare providers who erroneously frame accidents as a choice. The notion has seeped into psychiatry and psychology literature. Both enuresis and encopresis are listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA). The DSM-5 asserts that both enuresis and encopresis “may be voluntary or involuntary.”

The DSM-5 opposes any sort of punishment for accidents, but the book’s framing of the issue, which I dissect here, gives legitimacy to the idea that accidents may be a choice.

In his email to me, the 15-year-old boy credits his mom for not yelling at him, like his dad does, but adds: “She feels as though I need to take more responsibility to manage the issue. But I swear I am trying the best I can.”

Of course he is. But he can’t win, because no amount effort will stop his accidents.

Children internalize the blame heaped on them, and the damage to their self-esteem and mental health can be severe.

The 15-year-old told me he became so depressed over his bedwetting that he was hospitalized for attempted suicide. I’ve heard this story multiple times before. Lord knows what’s in store for the 3-year-old who was jailed by his angry parents.

But it’s not just the egregious examples of blame that crush children’s confidence. Even when parents don’t expressly blame their children — even when they understand, intellectually, that accidents are caused by constipation, not willfulness — their inadvertent sighs or eye-rolling may send a different message to the child.

Parents, understandably, express frustration when their kids deny having had an accident or secretly stash their dirty underwear in the trash. They wonder, “Why does he lie?”

Why? Because kids are afraid of angering or disappointing their parents.

In his email to me, the 15-year-old said his mom “gets annoyed when I lie about the wet nights.” But why would he tell the truth when his parents hold him responsible?

The Australian physiotherapist with the “good choice/bad choice” chart tells her patients — with a sad-face emoji and an arrow! — that accidents will lead directly to “sad/disappointed” parents.

I gained more insight into children’s feelings of shame last week from Tara Galles, MS, OTR, a pelvic floor therapist in Kokomo, Indiana, who treats children with enuresis and encopresis. Tara uses a Walkie Talkie to chat with her young patients, a brilliant strategy that allows kids to talk to her from a different room, without having to look her in the eye.

When kids talk into the two-way radio, she says, “the floodgates open up.”

Many children admit to hiding accidents from their parents because "they worry they'll get in trouble or that their parents will be disappointed in them."

Tara added: “It’s more painful for them to tell their parents they had an accident than it is to sit in wet pants. The shame is the worst thing."

Even though most parents try to avoid shaming their children, kids feel humiliation nonetheless. In the most egregious cases, shame is the entire point. The Florida lieutenant who jailed his son told a caseworker that his son sobbed the whole time, which was “the response I expected from him.”

This dad claims his punishment did the trick — that the boy has stopped pooping in his pants. If that’s true, which I doubt, the accidents are likely to come back unless the child receives treatment.

That’s the nature of encopresis. Poop accidents are relatively easy to stop, at least with an enema-based regimen such as M.O.P., but it takes several months for a stretched rectum to spring back and regain normal tone and sensation. So, unless the rectum is fully evacuated daily during that healing period, accidents are likely to recur.

It’s clear the boy’s accidents were ongoing prior to the jailing incident. His dad told the investigating caseworker that his previous strategies, whatever they were, had failed.

“Name something, I’ve tried it,” he said. “When it comes to getting him to poop on the potty and discipline, I’ve tried it.”

I’ll name something: treatment for constipation.

It’s tragic enough that kids with enuresis and encopresis are being punished and humiliated, but what’s worse is that these conditions are entirely treatable.

In addition to being shamed, these kids are being denied the treatments that will stop their accidents, restore their self-esteem, and allow them to go away to summer camps, sleepovers and college dorms.

Media coverage of jail case focused on the outrageous punishment, but this critical angle was overlooked. For example, in its article on the jailed 3-year-old, the Washington Post quotes a Mayo Clinic website describing accidents as “inevitable.”

But that’s untrue. Sure, a child might have accidents in the first few weeks of toilet training, but when poop or pee accidents persist — which clearly happened with the jailed 3-year-old — or when the child is averse to pooping on the toilet, it’s almost always because the child’s rectum is clogged. Not because the child is a "potty refuser."

Likewise, bedwetting is normalized in the media and by some physicians as a “developmental stage.” But “common” does not mean “normal.” Enuresis is a red flag for chronic constipation and should not be ignored.

I have loads of teenage patients with enuresis and/or encopresis. In the vast majority of cases, you can trace their accidents back to constipation that was, in retrospect, apparent by age 3. But their constipation was dismissed as “normal,” was woefully under-treated or, worse, was treated as a behavior problem.

The jailed 3-year-old is an extreme case, and I’m glad the incident received media coverage. But I worry that amidst the outrage, the public will miss out on a key message: Not only are accidents never a child’s fault, but with appropriate treatment, accidents can be stopped.

Steve Hodges, M.D., is a professor of pediatric urology at Wake Forest University School of Medicine, an authority on enuresis and encopresis, and the author of several books for parents and children, including Bedwetting and Accidents Aren't Your Fault and Emma and the E Club.


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