It’s Not Possible to “Fix” Kindergarteners Who Wear Diapers by Passing a Law. Obviously.

A Utah legislator has proposed a bill, H.B. 331, that would require students to be toilet trained before they are enrolled in kindergarten. The bill, sponsored by Rep. Douglas Welton, may sound reasonable, but it actually represents everything our culture gets wrong about toileting accidents. If passed into law, it will harm kids.

Let’s start with the bill’s rationale. In interviews with media, Welton has said Utah needs H.B. 331 because too many children are showing up for kindergarten in diapers, overburdening teachers. “That’s not what [teachers] signed up to do, to teach kids how to potty train,” Welton told the Salt Lake Tribune. “That’s a parent issue. That should happen before kids get to kindergarten.”

Welton’s bill requires “assurances from a parent that the parent’s student is toilet trained.” If the student then has bathroom accidents, the family would be referred to a counselor or social worker for support; the child would subsequently be “reintegrated” after they have “become” toilet trained.

But H.B. 331 is based on an erroneous assumption: that 5-year-olds who need diapers are not toilet trained. In reality, school-age children in Pull-Ups—like Steve’s patients at his practice in pediatric urology—are toilet trained, and were taught by caring and diligent, if frustrated, parents. Accidents have nothing to do with a lack of instruction or slacker parenting.

Rather, virtually all wetting accidents (enuresis) and all soiling accidents (encopresis) are symptoms of chronic constipation, a condition that’s misunderstood, overlooked, and undertreated. X-ray these kids and you’ll see a rectum enlarged to at least twice the normal diameter of 3 centimeters. You might even see, as Steve often does, a grapefruit-size stool mass that, for multiple reasons, went undetected by the referring physician.

How does this happen? Well, when children delay pooping, as they often do, stool piles up in the rectum, which stretches accordingly. In some kids, the oversized rectum aggravates the nearby bladder nerves, causing the bladder to “hiccup” forcefully and empty abruptly, day or night. (Most kids with daytime accidents experience bedwetting, too.)

Often, the stretched rectum loses so much sensation and tone—imagine a sock that’s lost its elasticity—that the child cannot feel the urge to poop, and/or fully evacuate. Stool just drops out of the floppy rectum, without the child noticing. (We know, this is a vivid image. But these are the facts!)

No amount of instruction, bribery, or legislation will stop these accidents. A clogged rectum will not respond to the promise of M&M’s or the threat of being denied entry to school. (Or the threat of incarceration. Not long ago, two married Florida cops put their 3-year-old behind bars to “teach him a lesson” about potty accidents.) Children with enuresis and/or encopresis wear Pull-Ups to school not because their parents didn’t bother to potty train them but to minimize the mess and embarrassment that will inevitably accompany an accident.

Twenty years as a pediatric urologist has taught Steve there’s only one way to get these kids out of diapers: treat the underlying constipation. That is, clean out the rectum and keep it empty on a daily basis, allowing it shrink back to size, stop irritating the bladder, and regain full tone and sensation.

H.B. 331’s solution? Bar entrance to the classroom and refer “the student and the student’s parent to a school social worker or counselor.” Unfortunately, a clogged rectum doesn’t respond to counseling, either. And social workers, like educators, aren’t trained to recognize accidents as a symptom of constipation.

Instead, these folks often attribute chronic accidents to behavioral or emotional issues—kids are considered “stubborn,” “attention-seeking,” stressed, or anxious. This idea is pervasive, not just in schools but in our culture at large. In TV and film, kids’ toileting accidents signal psychological distress, usually triggered by absent, working moms. (See: Borgen and Fleishman Is in Trouble.) In politics, the term “bedwetting” has become a synonym for “excessive worry.”

In Steve’s experience, students in diapers who are referred to school counselors don’t get the help they need. Worse, they’re subjected to treatment they don’t need. Schools routinely recommend counseling, art therapy, sticker charts, and potty training “action plans,” when what these kids actually require is a course of suppositories and Ex-Lax. Accidents persist, and kids feel like failures. How will they feel if they live in Utah and can’t even attend school? Over the years, Steve has had countless patients suspended from school, threatened with suspension, or simply humiliated into disenrolling because they couldn’t graduate from diapers.

Or take a case that was picked up by the media, in which a girl was declared “not potty trained” by her school for exceeding the school’s monthly accident quota and was escorted off the premises with her mom. Commenters on the Washington Post article about this case called her mom a “lazy person who wants to dump the kid off so she can shop and drink Starbucks.” One posted, “It’s narcissistic for parents to insist that their untrained child has to be indulged. A parent’s job is to raise a well-socialized, functional member of society.” An X-ray later showed massive constipation, and with treatment, the girl’s accidents stopped.

That’s an extreme form of the parent-blaming that underlies H.B. 331. Rep. Welton, for his part, said in an interview that he’s just responding to complaints from beleaguered Utah teachers. “We’re talking about parents coming in [to the classroom] saying, ‘We need you to change my kid’s diaper. She’s not potty trained.’ ” He added that he knows three teachers who are ready to quit because parents are “asking them to wipe their kids’ bums.”

According to Welton, this scenario is “pretty widespread” across Utah and, he has been told by teachers, something new, a post-COVID-closures phenomenon. Media have reported that classroom accidents in Utah have “sharply increased” since before the pandemic or even “doubled.” But is this true? All these alarmist stories link back to each other, never to data. Asked what data he’s using, Welton said, “It’s largely anecdotal right now,” though he said he was trying to obtain numbers from the Utah State Board of Education. At the time of publication, he had not provided them.

To be sure, every elementary school has students in Pull-Ups, not just in kindergarten, but in all grades. (Steve’s older patients, terrified of being outed, go to great lengths to hide their pull-ups, wearing extra-long tops and tying their sweatpants so tight the kids are practically trapped.) However, the “kindergartners in diapers” hysteria is nothing new, and not local to Utah. Back in 2014, we blogged on this very topic after a Spokane, Washington, newspaper declared, “Students Who Aren’t Potty Trained an Issue for Kindergarten Teachers.” In 2016, we dusted off our talking points when a British outlet reported: “Teachers Wasting Time Potty Training Kids Because Parents Are Too Lazy or Busy to Teach Them at Home.” We did so again in 2021, responding to another piece: “Teachers Report ‘Heartbreaking’ Rise in Number of West Australian Children Attending School in Nappies.” In 2023, a bit weary, we nonetheless rallied in response to “Teachers Are Seeing More Kindergartners Arrive at School Still in Diapers.” This time, the phenomenon was said to be happening “across the country.” Each time, the “trend” is attributed to lazy, ignorant parents—or, in the British story (as on TV!), “working mothers.”

Let us offer an alternative explanation: Schools themselves contribute to the accidents they’re so appalled by. To be sure, constipation has multiple causes, like highly processed diets, a sedentary lifestyle, and especially genetics. (Many of Steve’s patients became constipated in infancy, well before they could have encountered Lunchables or a video game.)

There’s also the modern concept of decency. It would not occur to a cat, or to our prehistoric ancestors, to delay pooping when the urge strikes. But today’s humans, particularly human children, are masters of delay. Basically, we’re too smart for our own good. If we’re not near a toilet when nature calls—if we’re in a car or at recess—we’ll override the signal.

However, preschool and K-12 policies clearly add to the problem. Preschool toilet-training deadlines, for example, prompt many parents to initiate training at a time we believe to be too early, increasing the odds a child will develop chronic constipation. It can take a few years before the rectum becomes enlarged enough to trigger accidents. So, it’s no surprise that kindergarten—when kids have fewer toileting reminders, more worries about interrupting the teacher, and more hours away from home—is often when enuresis or encopresis starts. Constipation that may have been held at bay finally reaches a point of critical mass, literally. Steve sees this all the time.

What’s more, K-12 policies often encourage students to override their bodies’ urges. Some teachers dangle “good behavior” prizes—trinkets, student-store “money”—to children who don’t use bathroom passes. The mom of one of my patients is an elementary school teacher who knows well the hazards of withholding, yet can’t give her own students more than four bathroom passes per quarter. In a University of San Francisco survey of 4,000 elementary teachers, 88 percent said they encouraged students to hold their urine. Some 36 percent of teachers reported rewarding students who didn’t use restroom passes or punishing those who did.

The lead author, a teacher turned doctor, told us her survey was inspired by witnessing accidents in her second grade classroom. “It’s just a horrifying experience for a kid,” she said. As a former teacher, she was sympathetic to the difficulties of managing a classroom, as are we. But as a medical student, she learned that ignoring the urge to pee only aggravates the bladder, compounding the effects of constipation.

Most teachers aren’t aware of this. A while back, first grade teachers at a Nevada school told parents, in a letter posted on social media, that “students are wasting valuable learning time on bathroom breaks.” The teachers asked parents to help their children “increase bladder endurance” by overriding their urges to pee.

Many of Steve’s patients literally never use the school restroom because they’re discouraged by teachers, worried about missing class, fearful of being teased, or grossed out by the toilets. During the pandemic, kids faced none of that, and, stuck at home, many of his patients reported having fewer accidents. Perhaps the post-pandemic return to school set some kids back, and that’s what the Utah kindergarten teachers are responding to. We don’t know.

In support of his bill, Rep. Welton pointed out in our interview that H.B. 331 exempts students who have an Individualized Education Program or 504 accommodation plan that describes a condition that precludes toilet training before kindergarten. This sounds fair, but isn’t. Certainly, Steve urges parents to secure 504 plans so his patients can bypass school restroom restrictions and other impediments to their recovery. But many parents of kindergartners in Pull-Ups don’t even know their child has chronic constipation, so pervasive is the notion that accidents are behavioral. Most parents have not heard the terms “enuresis” or “encopresis,” so they would never even think to secure a 504 plan for their child.

H.B. 331 states that kindergartens “are an integral part of the state’s public education system.” That’s true. And it would be callous to deny 5-year-olds participation in this system simply because they have a medical condition that society misunderstands.