Thursday
Jul072011

Our 5 year old is wetting his pants at school!

Every fall, after school has been in session for a few weeks, I start to get calls from parents about their children coming home with wet underwear.  Here is what they say: 

Our son D’Andre has been using the toilet since he was three and has never had a problem. We didn't even notice when or if he used the bathroom.  He just started kindergarten and all of a sudden he's coming home with wet pants!  Sometimes he says, "I forgot", but other times he acts as if he didn't even notice.  What could be going on? Is this stress?

A few weeks after our daughter Megan started kindergarten I thought I smelled urine on her clothes.  Sure enough, her panties were damp.  We talked to her and she acted as though she didn't know what we were talking about.  Then I found some rolled up underwear in the back of her closet--she was hiding the accidents.  We've told her that the other kids will notice the smell if she doesn't get to the bathroom, but she doesn't seem to be willing to try. Isn't this pretty unusual?

 

 D’Andre and Megan's accidents are not at all unusual for children beginning school. During the time of transition from pre-school to kindergarten some children who have never had any difficulty using the toilet may begin to have accidents, much to everyone’s surprise.

Moving from pre-school to regular school is a big leap forward.  Even if your child has been in a large group in pre-school the threshold of the kindergarten door is a passageway to a new kind of relationship between your child and his teachers.  Kindergarten teachers are usually very kind and understanding, but they have higher expectations of the children in the class for behavior, cooperation, and independence.  

At school, a new kindergartener is trying to learn many new things all at once.  There are new rules, activities, and usually the challenge of beginning to learn to read.  Even though a child may be very happy with her teacher, her friends, and all of the exciting things she’s learning, she will probably be feeling stressed by the new experiences. Stress alone is enough to cause some children to have occasional accidents, but other factors are usually involved as well.  

In many pre-schools, children are taken to the bathroom at regular intervals, or told "Time to use the bathroom" before nap or going outdoors. Not all kindergarten classrooms teachers plan for bathroom breaks in the same way, and a kindergartener may not get any reminders to “go”.  “Going” isn’t always easy, either.  Some kindergarten classrooms have their own bathrooms so that children don't have to leave the room and walk down a hallway to a bathroom shared by much older kids.  But the convenient location of the bathroom may cause the teacher to assume that the children don't need extra help!

I’ve asked kindergarten age children why they sometimes don't use the bathroom in their class and I’ve heard some answers that were a surprise to the teacher.  "Because it's dark in there until you turn on the light and I can't reach the light”. "Because it smells funny."  "Because when I come out everyone knows I just went to the bathroom."  "Because the window is open and the seat is really cold." 

In some school, the bathrooms are not in the class.  A child has to ask for permission to go, and then go out into a big hallway where all the other kids look like giants! 

The most common cause of children’s wetting accidents at school is not noticing the need to go to the bathroom until it's too late.  Children who have good focus when involved in an an activity are the children most likely to have accidents because they are concentrating so hard on their work.  Other children are so interested in what they are doing that they are afraid to miss anything by leaving the room to go to the bathroom.  It can help if a child has a way to tell the teacher or other kids to wait until he gets back before going on with an activity.

Sometimes a child doesn't notice that her bladder is full until it is really, really full.  At that point, she might let go of a small amount of urine just to be able to get to the toilet without letting it all out.  Even if she goes to the bathroom soon after that, she might have a wet spot that will start to have an odor. A child who gets to the bathroom quickly may be in such a hurry to finish that she doesn't empty her bladder completely and so she has to go again an hour later.

A busy teacher can be unaware that children in the class are having difficulties staying dry.  A parent might notice that a child is squirming or fidgeting in the way he usually does when he has to go, but to the teacher he might look like any other squirmy or fidgety child.   Of course, a teacher would notice if a child made a large puddle on the rug, but most accidents are quite small.  A teacher who is busy teaching is unlikely to pay much attention to a damp spot on a child's trousers or skirt. 

Parents who see the damp circles or patches on a child's clothing often assume that the child is "peeing in his pants".  Usually the child is not letting go of any more than a dribble, just enough to feel temporarily comfortable.  A small amount of liquid can appear quite large when it is placed on fabric.  Try pouring a tablespoon of water on your child's pants and you will see that even a little bit of urine might be responsible for what you thought was a big accident.  

Of course, even tiny amounts of urine will begin to give off an unpleasant odor after an hour or so.  The odor will be noticeable to parents and may be strong enough to be smelled by other children at school, (although they may not recognize what it is.)  However, most children will not be aware of the odor on themselves. Have you ever noticed that it’s hard to smell perfume a little while after you put it on yourself, but you can smell it when someone else is wearing it?  So if parents tell a child that his wetting is a problem because he smells bad, the child doesn’t understand what the parent is talking about!

If your child was completely toilet trained before starting kindergarten she should have the ability to take care of herself at school.  It's unlikely that she wants to have accidents.  However, when she is upset about having accidents she may deal with her feelings of embarrassment by pretending that she doesn't care.  If she is fearful of being scolded or punished, she may hide the wet clothing, hoping that her accident won't be discovered.

Parents can help children cope with the problem of having accidents in kindergarten in two ways.  The first is by planning ahead to avoid potential difficulties, and the second is by working with the child and the teachers at school if problems occur.

It's helpful to most children who are beginning kindergarten to visit classroom before school starts.  You may not be able to meet the teacher, and sometimes the rooms are not completely set up for teaching, but you can usually walk around the school.  Notice where all of the bathrooms are, go in, and if your child is able, have him try out the facilities.

When you meet your child's teacher find out about rules and routines for going to the bathroom.  If your child stays for an after school program, ask which bathrooms the children use and whether the younger children are given reminders or any supervision.  After your child has been in school for a few days, ask him to explain to you when the children use the bathroom and what the rules are.  Ask him, "Do any of the children in your class ever have trouble getting to the bathroom in time?"  Your child will have an easier time telling you about any difficulties he is having if you ask about other children rather than directing the question at him.  Of course, it is very likely that what he tells you will be true for him as well.

If your child does have accidents at school or you notice damp patches on clothing once he comes home, you can first talk to him about ideas for getting to the bathroom sooner.  Try not to talk to your child in a way that will make him feel embarrassed.   Since he is probably not having accidents throughout the day, ask him, "What are the times that you get to the bathroom when you have to go?  How are you able to do that?"  In that way your child can focus on what he is doing right rather than on what he is doing wrong.

If talking to your child doesn't help, the next step is to talk to the teacher.  Many children will not be able to talk to the teacher themselves because the subject will embarrass them.  You can ask the child to join you for a discussion or you can have the conversation without him.  Ask the teacher for ideas or suggestions.  A teacher may not be able to keep track of one child’s bathroom use, but many teachers are happy to give a reminder to stop at the bathroom before recess to one child or the whole class.  Once a teacher is aware that a child is having difficulty they are usually very willing to help.

At home, help your child to notice out how long he can go without needing to go to the bathroom in the evening and on the weekend.  Ask him to figure out how much he can drink in order to "hold on" for two hours or three hours or four hours.  Notice if his ability to "hold" fits with his breaks for recess or lunch.  He may need to adjust what and how much he drinks in order to stay dry.

Some children respond well to small rewards for dry days.  It is best to give small daily rewards rather than to expect a child to work toward a big reward in the future. Don’t work on staying dry for two days until your child is dry for one day for at least a week! Keep in mind that the best reward to your child for staying dry should be his own sense of competence, not an external reward.

These problems usually resolve after a few weeks. If despite your efforts your child continues to have accidents that don't improve over time, make sure that she’s also having regular bowel movements. Constipation and withholding bowel movements can also cause wetting accidents. The excellent book, "It's No Accident" by Steven Hodges, M.D., a pediatric urologist, explains this problem in detail.  If the accidents continue for more than a few months or if they become more frequent, check in with your child’s health care provider to rule out any medical causes.

Meg Zweiback is a pediatric nurse practitioner in Oakland, California.  She frequently consults with families when children are having daytime or nighttime enuresis.


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