Thursday, May 25, 2017
When Children Wet or Soil Themselves
When people write in to this blog with queries (or expostulations!) about children’s behavior problems, it’s frequent for them to mention that their school-age children still wet themselves in the daytime or urinate in strange places, and that some even defecate in their pants or in some hidden place that is revealed only by the smell. Frustrated and angry, the parents often feel that the children are doing these things intentionally as hostile actions toward the adults (and often the parents think that such hostile actions would be a sign of an attachment disorder—but I don’t want to get into that today).
As it happens, a child clinical psychology listserv that I participate in has recently been having a discussion about exactly this. One member had written in to ask for suggestions about working with a ten-year-old girl who was defecating in her pants. An interesting discussion ensued, and I want to summarize some of what was said and elaborate on some of the ideas.
A most useful point made by several people was that many of the children with these behavioral elimination problems were never completely toilet-trained in the first place, and the behavior of those children is an indication of their lack of mastery rather than their hostile intentions.
Consider what happens when a functional, “normal” family toilet-trains a child. First, the fact is that the parents have been communicating to the child for many months that there is something special about elimination. It’s not like drooling or even like spitting up. There is an emotional response to urine or feces, a strong motivation to clean them up and get rid of them, that is communicated to the baby by attentive, engaged parents. They sniff the baby or peek down her diaper to see what needs to be done. When changing a dirty diaper, they pay attention to the diaper and not the baby, complaining quietly if the baby kicks and gets her heel into the mess. Caregivers talk to each other in front of the baby: “Did she poop?” “yes, and what a smelly mess it was!”. If the baby is just wet, the diaper change is much more relaxed and probably involves some smiling, talking, and playing. In all these ways, a well-cared-for family baby is learning for a long time that something about elimination is special and important, and that urine and feces are different.
Well-functioning families also pay attention to whether a baby seems ready to be trained, whether she seems to be aware of bowel or bladder pressure, and whether she has the words to ask for help. Caregivers “talk up” using the potty or toilet, with the reward of big-girl or big-boy underwear held out for encouragement. Once the child has some success in managing elimination, adults follow him around reminding him, asking if he needs to go, paying attention to cues like dancing the “potty dance” or passing gas that indicate elimination is about to happen. They give careful instruction on the use of toilet paper, and may give boys paper “targets” floating in the toilet to practice their aim. Toilet “accidents” may or may not be punished, but certainly adults tend to respond to them with some degree of exasperation once they think a child has mastered the basics and just needs to pay attention.
These common and effective methods of toilet-training only happen under certain circumstances: The child is being cared for by people who have the time and energy and motivation to do the job. The child is being cared for by people who know him or her well, understand the child’s language or other communication, and are not completely distracted by other needs or obligations. The caregivers are thus able to be consistent and to predict elimination, so the child is helped to understand what events are likely to follow certain internal sensations. After all, to be completely toilet-trained, a person must be able to recognize internal cues and to understand the time available to get to the toilet once certain sensations occur. A child is not completely toilet-trained if he has to depend on others to tell him when to go.
As you can see, all this work by caregivers is not so likely to happen if a child has been passed from foster home to foster home, has been in the custody of an adult who uses drugs or alcohol or who is physically or mentally ill or who lives in a frightening environment. Some adults in these circumstances will focus on punishment following inappropriate elimination as their main toilet-training strategy; this is not only emotionally problematic but would be difficult to do effectively even by a skilled user of aversive methods. In addition, caregivers who use punishment in this way often do it inconsistently and out of irritation—even when a child defecates in a recently clean diaper.
Although some children may become completely trained under those conditions, others will not. Later in their lives, in school or in an adoptive home, toilet “accidents” may occur repeatedly and even may appear to be intentional because children do not seem to feel guilty or concerned. By that time, negative attitudes of adults and of other children to the child himself or herself, not just to the toileting problems, may begin to have effects on the child’s mood and behavior, further complicating the difficulties.
So what to do when this situation has developed? The first consideration is about medical problems that may cause toileting difficulties. (As one participant in the listserv discussion I mentioned earlier said, the causes are often thought to be volitional, but they are probably biological.) Urinary tract infections may be involved. As for inappropriate defecation, strange as it may seem, these children are sometimes suffering from constipation, with hardened feces held in the intestines, but softer feces passing around the hardened part and being passed involuntarily or leaking. This problem may have developed because children are afraid to use the toilet or because it has been painful to pass hard stools and the child is actively resisting this. If constipation is a problem, children may need to be treated with stool softeners and with changes in diet that can return them to a healthier elimination pattern.
Behavioral treatments are also useful, especially if a child has found defecation painful and needs to be rewarded for sitting on the toilet at first and later for defecating there. Frequent reminders and rewards, given in an encouraging and nonpunitive way, are needed until the child has some success.
If urinary problems are not caused by medical issues, the problem may be that the child has not learned to associate the sense of a distended bladder with urination soon after. Encouraging the child to drink large amounts of fluids and then measuring the urinary output (with a bucket or some other device) can call his or her attention to the connection between the two.
Children who have toilet difficulties of these kinds may also have other mood or behavioral problems, including defiant, oppositional, or callous-unemotional behavior, but it is probably a mistake to assume that the toilet behavior is just another aspect of defiance or opposition. The two kinds of problems are likely to have different causes and to need to be treated differently.
Need I say that when children are locked in their rooms, or when door alarms are used so that they have no free access to toilet facilities but must use buckets to eliminate or wait as long as they can, difficulties in controlling elimination are likely to emerge even if they were not present before? Limiting foods, as in the peanut-butter-sandwich-and-milk routine advised at one time by Nancy Thomas, is likely to play into any tendencies to constipation. Incidentally, I understand that the said Nancy Thomas, now touring Russia to spread her beliefs, is recommending that children with poor bladder control must wash their clothes by hand with cold water and vinegar; this is not likely to accomplish anything but to increase anxiety and lessen the child’s ability to control urination.