“My four-year-old, who has had potty training, consistently urinates on himself at night and even during the day while he’s awake. His response is that he doesn’t care about using the bathroom and doesn’t want to stop his playtime in order to use it. I’ve tried everything from rationalizing with him, encouraging and congratulating him when he goes to the bathroom, and admittedly even putting him in timeout or taking away his toys when he urinates on himself. He has not experienced any recent trauma that I’m aware of. There haven’t been any major changes in our family that could possibly be connected to this. Nothing seems to be helping, I would appreciate your insight.”
In this episode, I will address a very common issue, potty training regression, especially when kids claim they just don’t care or don’t want to stop playing. I will give some background on what is appropriate for different developmental stages, discuss potential underlying issues, and provide strategies to get them to want to keep their pants (and bed) dry.
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Critical to consider a child’s developmental level and context when assessing toileting behaviors
- Young children can struggle with toileting during the day and/or night, especially if they have any sensory processing issues or are easily dysregulated
- It is normal for kids at these younger developmental stages to struggle with consistency with their toileting
- Although frustrating for parents, keep in mind there are many potential underlying issues that can contribute to a child regressing or lacking interest in being fully toilet trained
- Was the child ever capable of stopping and using the bathroom when needed during the day without being prompted?
Habit Trained vs. Toilet Trained
- Habit training: when the child is brought to/put on the toilet, they know to urinate or defecate
- Toilet trained: in addition to the child knowing to urinate or defecate when on the toilet, they are also aware of the sensations and are independently able to get themselves to the toilet.
- Has the child developed the underlying brain-body connection that’s necessary to recognize when the body is sending a signal of needing to empty the bladder or empty the bowels?
- It is not uncommon for young children to struggle with night wetting as they are still within the range of what is developmentally typical
- Some kids, once they are day-trained, pretty quickly stay dry at night, for others it’s a much longer process
Sense of Interoception
- There are five well-known senses, but there’s also interoception sense, which is our sensation and awareness of internal body signals
- Examples of interoception include awareness of being cold or hot, hungry or full, urge to empty the bladder or bowels, etc.
- It’s critical, especially to be successful with toilet training, to have a strong brain-body connection; to have an awareness of those sensations, and then know what to do in response to those
- It is typical for kids with sensory processing challenges, ADHD, or other kinds of neurodevelopmental issues, with trauma backgrounds, or just developmentally young, to often struggle with interoception-related processes
- When a child claims they just don’t want to stop playing to use the bathroom and would rather soil their clothes, typically there is a deeper issue because kids, in general, want to please and do the right thing
- Important to remember that when kids are uncomfortable or embarrassed, they will deny all kinds of things.
- In this case, they may not have the mind-body awareness that the body even needs to use the bathroom or understand the consequences that would follow
Tools & Strategies to Build Interoception
- Build their connection between their brain and body for awareness of sensations in general, such as having them touch a warm vs cold washcloth. Can they identify it? Can they tell if something feels wet or dry? Seems simple but powerful
- Model interoception: such as describing out loud what it might feel like when you are hungry, thirsty, or have a full bladder, and then going and doing that thing
- Occupational therapists are a great resource for interoceptive curriculums and activities
- Toileting alarm systems are discrete and effective for all ages
- Schedule bathroom breaks throughout the day
- Use a visual bathroom schedule if needed
- Help them be successful throughout the day with staying dry, that in itself can help curb the wettings
- Top tip: Do not ask them if they need to use the bathroom, instead tell them it’s time, and if needed, escort them to the bathroom
- If they protest, acknowledge them “I get it, you don’t feel like you have to go. You don’t want to do it. But here’s why we’re doing it”. This is not a punitive tone but rather factual
- If at any point the situation has turned into a negative cycle and power struggle, perhaps a break is necessary so it doesn’t become a deeper issue. If so, stop focusing on it and either put the child back in pull-ups for that period of time or just deal with the mess and let it be what it’s going to be.
- Approach toilet training with the concept of “natural consequences”
- i.e. what are the things that just naturally have to be taken care of when X happens, such as having a urine accident?
- Stay calm but firm about what needs to happen and not in a punitive manner. Have them help if possible. “You had an accident, we’re going to need to clean that up”
- Or setting a boundary based on what is going to be appropriate, such as they can only play on the hard-surfaced floors because you don’t have time to clean the carpet if an accident happens
Medical & Physiological Components
- Constipation causes a big problem with urination. When painful, a child is more likely to resist to toilet train
- Large amounts of stool in the colon causes significant pressure on the pelvic region and can desensitize a child’s ability to register the urge
- Microbial overgrowths such as candida, yeast, or chronic UTI’s could be a cause, this is especially important to check if suddenly regressing
- Nutrient deficiencies: omega 3 fatty acids, B vitamins, zinc, iron
- Undiagnosed or untreated food sensitivities, food allergies, or environmental allergies
- Check all medication for side effects in both prescription and over the counter
Episode Intro … 00:00:30
Listener’s Question … 00:00:55
Child Development and Toileting … 00:01:54
Habit Trained vs. Toilet Trained … 00:02:41
Bed Wetting … 00:05:35
Sense of Enteroception … 00:06:08
Build Interoception … 00:08:40
Medical & Physiological Components …00:19:00
Episode Wrap up … 00:22:38
Hi, everyone, welcome to the show. I’m Dr. Nicole, and on today’s episode, I’m answering a question from one of you. I get many questions each week and this is a great opportunity for me to be able to provide answers that a lot of you might find helpful. If you have a question you’d like me to consider answering on a future episode, email it to firstname.lastname@example.org, and you just might hear it on an upcoming show.
Now on to today’s question, which comes to us actually from an anonymous mom, and she writes “My four-year-old consistently urinates on himself at night and even during the day while he’s awake. His response is that he doesn’t care about using the bathroom and doesn’t want to stop his playtime in order to use it. I’ve tried everything from rationalizing with him, encouraging and congratulating him when he goes to the bathroom, and admittedly even putting him in timeout or taking away his toys when he urinates on himself. He has not experienced any recent trauma that I’m aware of. There haven’t been any major changes in our family that could possibly be connected to this. Nothing seems to be helping, I would appreciate your insight.”
Well, to this anonymous mom and any of the rest of you who are dealing with these kinds of toileting behaviors, concerns, issues with your kids, I hope I can provide some helpful insights, some big picture things as well as some specific strategies. So, let’s start with: First, this mom is saying that her child is four years old, and I think a child’s developmental level is really critical to consider when we’re talking about something like toileting because it is still within the range of ca Don’t ask your child, “Do you need to use the bathroom?” You tell them “It’s time to use the bathroom”, and then help escort them there if they don’t go on their own. Asking a child “Do you need to use the bathroom?” Knowing that this is a child who has a history of not wanting to stop what they’re doing, or now we’re discovering that what’s more probably going on there is they don’t have good brain-body connection, they’re not aware of the signs their body is sending them. normal for kids at these younger developmental stages to struggle with consistency with their toileting, especially if they tend to have some sensory processing issues or are easily dysregulated. There can be lots of underlying things that can contribute, but it’s important to recognize that a four-year-old who’s having these issues, yes, it’s frustrating for the parents, yes, it’s something that you are motivated to work on and address, but I just always think it’s important to put these things in developmental context.
Now, I don’t know — it’s implied in this question, but I don’t know for sure that this is a child whose parents feel was day trained for using the toilet. A child who maybe they had worked with on toilet training, and they feel is capable of stopping and using the bathroom when they need to and staying dry during the day, that’s implied here, although I don’t know that that’s true. Again, when we think about this developmentally, it’s important to consider what’s going on with that. Sometimes, parents believe that they have toilet trained a child, which really means that the child not only is able to stand or sit at the toilet and urinate or have a bowel movement, but that they are aware of the sensations and are independently able to get themselves to the toilet in order to do that. That’s truly what being toilet trained means; what being independent with that is all about. So it’s important to consider that because sometimes parents believe that they have toilet trained their child, but actually what they’ve done is habit trained their child. Habit training is different. Habit training means that the child knows that when they’re put on the toilet, or when somebody stands them in front of the toilet, or brings them to the toilet, that they urinate or defecate, that’s habit training. That’s obviously a very different thing. Because that does not involve the key skill that we would like our kids, if they’re able to, to be able to identify for themselves the sensations that let them know that they need to do that, and go on their own to do that. So it may be that this child was habit trained, not truly toilet trained, I’m not sure. And I will say that some of you, if you have a more significantly developmentally-delayed, or neurodevelopmentally-impaired child, or a child with significant medical needs, or cognitive disabilities, habit training is sometimes what our goal is. For various reasons in terms of how that child’s brain and body works or doesn’t work in ideal ways, that habit training is what we’re trying to accomplish. But for typically developing kids and the vast majority of kids, even those who have neurodevelopmental issues or diagnoses, developmental delays, those kinds of things, toilet training is very possible, but we have to understand developmentally what’s going on here. So it may be that this child was habit trained and hasn’t really developed the underlying brain-body connection that’s necessary to recognize when the body is sending a signal of needing to empty the bladder or empty the bowels, and being able to do that. I’m going to say more about that in a minute. The other big picture thing I want to touch on here, before we dive into specifics, is this mom also mentions night-wetting. And again, I will say that within the range of what is developmentally typical, a four-year-old who’s still having night wetting, that’s not all that unusual. Some kids, once they are day trained, pretty quickly stay dry at night, for others it’s a much longer process. And as a four-year-old, it’s certainly reasonable that they would still be having some wetting accidents at night, so I just want to put that out there again, big picture developmental context.
Now, let’s get into some specifics, and let’s talk about this idea of interoception, which I just introduced without using that vocabulary word, which is being aware of your internal sensations. When we think of the senses, we think of the five senses: What we see, what we hear, what we smell, those, but we actually have a sense called interoception, which is our sensation of internal body signals. Feelings that come from inside of us. So, things like is this hot or cold? Is this wet or dry? Am I hungry or am I feeling full? Do I need to empty my bladder? Do I need to empty my bowels? These are all interoception-related processes and sensations. Sometimes kids really struggle with the brain body connections, to have an awareness of those sensations and then know what to do in response to those. Very typical for, again, developmentally young kids, very typical for kids with sensory processing challenges, for kids on the spectrum with ADHD, or other kinds of neurodevelopmental issues, very common in kids with trauma backgrounds. So there can be lots of reasons why interoception isn’t strong for a child, but it has a ton of important implications for toileting, because a child can’t be independent with their toileting if they don’t have a strong brain-body connection, a strong awareness of those internal sensations, and then knowing what to do with them. So some things to work on there if you know that your child is struggling with this, and even in this case, the child is telling their mom, “No, the problem is I just don’t want to use the bathroom.” I find that very hard to believe. Kids say that all the time, and usually when kids say that “I just don’t want to stop playing,” There is something else going on there, because kids do well if they can, kids in general want to please, they want to do the right thing. So my guess is at a minimum, there are some interoceptive difficulties going on there, and possibly some other things too, even though the child is denying it. Kids will deny all kinds of things, typically because it’s uncomfortable to them to deal with or talking about, there may be embarrassment around it, there may be shame around it, or they truly aren’t aware. They truly are not aware of any of the things that are going on, and so to them, it’s like, “Well, I just don’t want to stop playing”.
So thinking about strengthening this sense of interoception, you want to do lots of things that help the child build connections between their brain and their body for awareness of sensation in general. So even playing a game of touching different things that are different temperatures, (obviously, safe temperatures, not like a burning hot stove). But things like a warm washcloth versus a cold washcloth, seeing if they can tell the difference. Can they label that? If you put a warm water washcloth on different parts of their body, can they identify where they’re feeling that wetness, and also what temperature it is. Wet and dry, playing games and “Let’s see, I’m going to rub this paper towel on your back. Can you tell if it’s wet or if it’s dry?” These may seem like some really basic things, but a lot of kids who struggle with lots of things including toileting, when we get down to it and we do some of these kinds of experiments, we practice with these things, we realize “Oh my goodness, they are not attuned to any of this at all.” Thinking about things like “Oh, are we hungry? Do we need a snack? You modeling, modeling your cues like “Oh, my stomach is growling and I’m noticing I’ve got a little bit of a headache. My mouth is feeling kind of dry. Boy, my body’s telling me I need some water, I need to eat a snack.” Modeling those things. “Oh, boy, I’m noticing my bladders feeling full. I’m feeling like I need to use the bathroom”, sort of modelling, pausing, talking out loud about what’s going on in your mind, and then going and doing that. That modelling of those interoceptive cues is really valuable. So we want to be working on that. Occupational therapists can be a great resource. There are some great interoceptive curriculums and activities and things that are available that you can look at if you want to delve more into that. But that’s a key thing to be looking at if your child is having a lot of wetting issues, and if they don’t seem to even care about it. If they don’t even notice or seem to care, that is a huge indicator that they are not even from a sensory standpoint, they’re not even aware of the wetness running down their leg, or maybe of the smell of their clothing, or their underwear. To us, it seems so obvious, but they may not be. And that’s a clue that you need to do some strengthening of that interoceptive system.
So at a more extreme level, for kids who are really struggling with that stuff, and really struggling with the awareness, you can use certain toileting alarm systems. Now these are often used at nighttime for older kids who are still struggling with bedwetting to help alert them, to wake them up and have them use the bathroom the second they start to urinate. But these can be helpful during the day too, especially for kids who really lack that ability to tune in, and that brain connectivity to their body to go, “Oh, I need to go pee.” So you can use these little alarm systems. They’re not obvious to other people, you can use them even just when you’re at home, and that will help to alert, help the brain to start to cue in more clearly to those body sensations.
So that’s one realm of things to consider and think about. Another strategy that may be helpful in a situation like this is to be intentional about scheduling bathroom breaks throughout the day, to say, “Okay, my child doesn’t seem to be aware, he’s not stopping what he’s doing. Let me as the adult scaffold or support that a bit by doing some scheduled bathroom breaks. So maybe you’re intentional about letting him know that it’s time to use the bathroom at certain times of the day, before you leave the house, maybe “Okay, morning playtime is done, we’re going to head outside now for a walk, we’re going to use the bathroom.” That really is putting ownership on you as the adult to be aware of the timing and think about that, but that can be helpful here, especially if a lot of negativity and power struggle has built up around these wetting accidents all day long. Just schedule them, help him be successful throughout the day with staying dry. And that may help curb this as well. So you taking on the responsibility of bathroom breaks, maybe setting a timer on can help, maybe having a visual schedule where you have potty on there a few times or bathroom breaks. Even with older kids, it can be beneficial in the classroom. Sometimes I’ll have teachers set a little timer for themselves so that they can remind a child with challenges a few times to make sure they’re using the toilet. You can do that at home as well. Now it’s key here — hear me out, this is really important if you’re going to do this: Don’t ask your child, “Do you need to use the bathroom?” You tell them “It’s time to use the bathroom”, and then help escort them there if they don’t go on their own. Asking a child “Do you need to use the bathroom?” Knowing that this is a child who has a history of not wanting to stop what they’re doing, or now we’re discovering that what’s more probably going on there is they don’t have good brain-body connection, they’re not aware of the signs their body is sending them. Asking a kid like that, “Do you need to use the bathroom?”, the answer is always going to be “No.”, and that probably is not always accurate. So instead, we phrase it as a statement: “Time to use the bathroom”, and then take them there. If he protests, “I don’t want to, I don’t want to do it”, you say, “I know that it feels that way to you. I know, it feels like you don’t need to do it or you don’t want to do it. But I’m going to have you try because sometimes you don’t notice what your body’s telling you, and it’s really tough for me to clean the car if you accidentally pee in it.” Or “We’re going to have to cut our time at the park short if we get all the way there and you accidentally wet your pants.” So this is not punitive, this is not, “You have to use the bathroom now because I don’t want to clean up your mess.” No, this is more just appreciating what your child is communicating, “I get it, you don’t feel like you have to go. You don’t want to do it. But here’s why we’re doing it”, and just being clear about that. So hopefully those are some helpful strategies there.
Another approach to this, again, not having a lot of detail about exactly what’s going on previously, I’m just throwing out lots of possibilities that hopefully are helpful to all of you dealing with this. Another possible approach that would be helpful is to just back off and stop focusing on it for a while. To say, “Okay, I need a break for myself dealing with this, he needs a break from dealing with this”, and stop harping on it, stop focusing on it and either put the child back in pull-ups for that period of time, or just deal with the mess and let it be what it’s going to be. Sometimes we get entrenched in such a negative cycle and power struggle around this that is really not conducive for us or the child to move forward. So you may just decide that you and they need a total break from this right now, and that could be a valid strategy. The other thing that I think is important to think about from the how we handle this behavioral standpoint, is to think about the idea of natural consequences. I don’t encourage approaching this in a punitive way at all, “Ugh, look, you peed on the floor again. I can’t believe you did that. Now you’re going to have to clean it up”, that is going to bring up all kinds of negative relational things, emotional things that are going to really make this power struggle worse, are going to have the child attach a lot of negative emotion and feelings around this. It’s not going to be helpful. So instead, we want to focus on the natural consequences, which means what are the things that just naturally have to be taken care of when you have a urine accident, for example? So it might be having him help you clean up. You stay very calm, but very firm about what needs to happen. You walk into the playroom, maybe you say, “Oh, I see pee on the floor. Oh, I see that your pants are wet. Oh, I’m smelling urine. You had an accident, we’re going to need to clean that up.” And that could look like him going to the bedroom with you too. Now, that might look like having him come to the bedroom with you and changing his clothes, taking his wet underwear and putting them in the laundry room or in the washing machine. That might include having him get some cleaning supplies and helping you wipe up the floor, vacuuming, whatever that might be. Again, these are not punitive, it’s not “You did this, so now you are punished with this,” It’s just a natural consequence. “Oh, the floor is wet, that needs to be cleaned up. Oh, your pants are wet, you need to change those”, and doing that together with the child. Even young ones can participate in some of that, and that’s important because if you’re always coming in and just managing it and taking care of it, that’s not helping them to get the natural connection between what’s happening, and then the cleanup and whatever needs to happen on the other side of that. Another natural consequence could be setting a boundary and a limit that he has to play in areas where the floor or the space isn’t easily damaged and can be easily cleaned. And he might say, “No, I want to play where there’s the carpet!”, and you say, “You know what, buddy? I get that, but I don’t have time to get the carpet cleaner out and clean urine out of the carpet today if you have an accident. So you’re going to need to stay here in this room where it’s easier for us to clean the floor.” Again, you’re not saying that in an accusing or punitive way. It’s just a fact. You’re setting a boundary around that based on what is going to be appropriate for your belongings, for the care of your home, for your time schedule, those kinds of things. So thinking about some of those natural consequences can be helpful.
The last thing I want to touch on here around this whole issue are the physiological components that might be going on. Again, I don’t know this child whose mom is asking the question, I don’t know any of you that are listening. I don’t know the history or the details of your kids, but I want to share with you some of the medical and underlying physiological things that I often see in the clinic are connected to chronic wetting kinds of issues, daytime or nighttime, and kids who are really difficult to toilet train. The first is constipation. Constipation is a real problem for toilet training, not just for bowel training, which is obvious if they’re having pain, they’re going to be usually more resistive to having bowel movements on the toilet. But constipation also causes a big problem for urination. Because having stool in the colon chronically, large amounts of stool in there because they’re constipated, sort of puts this constant pressure on that pelvic region and makes it really difficult over time for kids to register sensation of the pressure from their bladder that they need to urinate. They just get desensitized to that pressure in that entire area. So constipation can lead to wetting problems. Also, I have found that Candida or yeast overgrowth problems in kids very often connect to wetting symptoms, especially if you have a child who was toilet trained, day or night trained, and now suddenly they’ve regressed and they’re not, look at yeast overgrowth issues. chronic UTI’s, urinary tract infections, can also really throw a wrench in toileting, can make that very difficult, can reduce accurate brain-body connection and sensitivity to the signs that they need to urinate, can make kids really resistive to using the bathroom. So you want to look at that to see if that’s an issue. There are also specific nutrients that can be connected to wetting difficulties and chronic issues in this arena for kids. Omega-3 fatty acids are really important for building the neural connections for this kind of sensation, awareness for brain body connectivity. Iron and zinc are two minerals that play key roles in sensory processing and again, the development of those brain body connections and those kinds of awarenesses. B vitamins also play a critical role here, not only in the sensation pieces, but also in a lot of regulatory functions and have been very tied to ongoing night wetting issues in children, including older kids. So we don’t want to ignore the role of nutrient levels and nutrients in this.
Also, I have seen that kids with undiagnosed or untreated food sensitivities, or food allergies, or even just allergies, can be environmental allergies too, but very often, food sensitivities or allergies can have a lot of issues with chronic wetting. So when we figure out what the food is that’s creating the issues for them, they do much better. Dairy and gluten are two of the big ones that I see for that. The other thing that you want to just consider is if your child is taking some medications on a regular basis, whether that’s a prescription medication for some reason, or over-the-counter medication, sometimes those can have side effects of wetting issues in kids. So you don’t want to ignore the impact that those may be having. So that gives you some potential physiological things to be thinking about and working on.
That was a lot of pieces to think about there. I hope there were some things in there that were helpful for the parent who wrote in about this, as well as the rest of you who are struggling with wetting kinds of issues in your kids. Remember, if you have a question you’d like to hear answered on a future episode, please email it to email@example.com. Put “Podcast Question” in the subject line and I’ll try to get to as many of those as I can on future episodes. Thank you, as always, for being here and listening, and I’ll catch you back here next time.