Autism and Constipation: Can Constipation Cause Potty Training Accidents? with Dr. Steve Hodges

In this interview with Dr. Steve Hodges we are discussing a really important topic, that unfortunately is not talked about often enough. Dr. Hodges is a pediatric urologist who specializes in constipation.  We talk all about the challenges with potty training and the challenges with treating constipation, specifically in kids, teens and adults with autism. We even talk about the signs of constipation and issues in babies.

Constipation in Children When to Worry

Many parents and professionals do not realize that most potty related issues are caused or related to constipation. Dr. Hodges shares a few examples from his practice in which accidents were solved by finding and treating a large mass of poop found in the colon via X-Ray. Constipation is an urgent medical issue and should be treated as such. It’s important to pay attention and be aware of the size, frequency, and consistency of bowel movements for any child who is having potty issues. What can cause constipation? This could be antibiotics, a change in consistency, pain, or any aversion to pooping.

Enema for Toddlers with Constipation

In addition to miraLAX, other laxatives, and suppositories, enemas are a quick solution for constipation. While an enema may seem extreme, from a scientific standpoint they are the quickest and most direct solution to the problem, a mass or build up of poop in the colon. A child may still be going to the bathroom and having accidents even through a buildup, so an enema is going to clear up that blockage and allow a smoother transition for potty training, preventing accidents and further constipation. Dr. Hodges and I discuss when to use an enema and the best practice for giving them to typical children and those with autism or developmental delays. Dr. Hodges has a wealth of knowledge on this subject and has helped many families with the stress that comes with potty issues. You can find  great information that pertains to your situation from his books,  The Pre-M.O.P Book and The M.O.P Book. He also has several options for Facebook groups both free and paid that provide a private, safe, place for questions and support for constipation, bedwetting, and other potty accidents and issues.

From time to time, BBC Materials may discuss topics related to health and medicine. This information is not advice and should not be treated as medical advice. The medical information provided in the BBC Materials is provided “as is” without any representations or warranties, express or implied.

You must not rely on the information in the BBC Materials as an alternative to advice from your medical professional or healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment for yourself or an individual in your care as a result of any information provided in the BBC Materials.  All medical information in the BBC Materials is for informational purposes only.

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Autism and Constipation

Dr. Hodges on Turn Around Autism Podcast

Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and an expert on bedwetting, toilet training, and constipation. The author of numerous scientific journal articles, Dr. Hodges also has written several books for families, including “Bedwetting and Accidents Aren’t Your Fault” and “The M.O.P. Book: The Proven Way to STOP Bedwetting and Accidents in Toddlers through Teens.” A father of three girls, Dr. Hodges is on a mission to educate families about enuresis and encopresis, conditions that are misunderstood, stigmatized, and inadequately treated.


  • Can constipation cause problems with urination?
  • How to relieve constipation in babies.
  • Constipation in children and when to worry?
  • How to give enemas and suppositories to young children.
  • Why constipation is a serious problem.
  • Potty training with exposure versus force.
  • Can a potty schedule damage potty training or cause constipation?
Want to get started on the right path and start making a difference for your child or client with autism?

Transcript for Podcast Episode:158
Autism and Constipation: Can Constipation Cause Potty Training Accidents? with Dr. Steve Hodges
Hosted by: Dr. Mary Barbera
Guest: Dr. Steve Hodges

Mary: You're listening to the Turn Autism Around podcast, episode number one hundred and fifty eight. Today I have Dr. Steve Hodges, who is a pediatric urologist, talking all about constipation, potty training, bedwetting and daytime accidents. And he is a wealth of information. I've been following Dr. Hodges for well over a decade, and he is an associate professor of pediatric urology at Wake Forest University School of Medicine. He is a real expert on all of these topics with books, and he has a clinic in North Carolina, as well as a few Facebook groups. We talk all about the challenges with potty training, the challenges with treating constipation and specifically with kids, teens and adults with autism. We even talk about the signs of constipation and issues with babies, and we talk all about how to treat them right here in this episode. So let's get to this episode with Dr. Steve Hodges.

Welcome to the Turn Autism Around podcast for both parents and professionals in the autism world who want to turn things around, be less stressed and lead happier lives. And now your host, Autism Mom, Behavior Analyst, and bestselling author Dr. Mary Barbera.

Dr. Steve Hodges on the Turn Autism Around Podcast

Mary: So, Dr. Hodges, it is so great to finally get you on the show to talk about potty training and constipation, all kinds of potty problems that the parents and professionals in our autism field deal with. So thank you so much for your time today.

Dr. Hodges: Thanks for having me. We're really excited to talk about this subject, which I think is kind of not not discussed enough.

Mary: It's not. And I have done a lot of work on potty training as a registered nurse and a board certified behavior analyst and a mom. So in my first book, The Verbal Behavior Approach, there's a chapter in here and there's a chapter on Potty. Also in my new book, Turn Autism Around, and I have a free potty guide, which is like twenty five pages that we can link in the show notes as well. You can get that for free. So I have been developing my expertize over the years. I was always a neurologic nurse, so I dealt with a lot of incontinence and that sort of thing. So it came naturally to me to deal with this subject, which is really tough. But you are a pediatric urologist. And so how did you fall into the world of basically being a doctor that deals with constipation?

Dr. Hodges: Yeah, this question. So we deal with two basic things we deal with, like congenital anomalies of the urinary tract or genitalia, and then we deal with peeing problems in kids. And so that includes daytime wedding, nighttime wedding, UTIs and so forth. And a lot of those issues are actually caused by constipation, and it almost becomes a cliche like, you know, oh, it's just it's just a. And that but honestly, it's a significant factor. Now most urologists in the country don't see patients their non-surgical, they'll see, you know, the surgical patients. And then if there is a child with what we call dysfunctional elimination or bowel and bladder dysfunction, we'll go to a kind of a physician extender, maybe a nurse practitioner, and they'll run the traditional cookbook protocol for those treatments. I was in a setting where that was not available, so they were all seeing me and I was running the cookbook protocols and I was getting poor results. And so Cory's

Mary: Cookbook being like, prune juice, increase your water, wake them up at night.

Dr. Hodges: Yeah, basically basically everyone knew poop was an issue. Someone gets miralax, they get time voiding and they get maybe some medications, like there's some medications we have that can relax the bladder. They don't really work that won't get into that and these kids. And so that was, you know, and come back and they would rinse and repeat. And I was getting frustrated as to why, you know, I don't like being in the clinic, come back the same problem and I have nothing to offer them. You know, it's frustrating for me and the parents, so I feel like I've the stories. I told this story so many times and I don't want to bore anybody, but it's an interesting story. So what happened was that I had a kid that was had kidney reflux. You may be familiar with that. So she was having a lot of kidney infections, bladder infections and kidney reflux. You can be born with it, but it can be made worse or persist, or you can have more infections if you're constipated. So one of the things to do is to fix that. And a lot of girls that went to bed also have you. It's all related. It's a nice girl from a nice family. Well, they were doing everything I needed to do with the more lax in the time for. And but she did not progress, and so she needed surgery for a condition, so she moved on to surgical options. When I did the surgery, I had a difficult time because there was a large, massive poop in a rectum. So like, I made the floor the bladder abnormal kind of was pushed up and angled in a way. I was like, Jesus is not pooping once. And I went and talked to family afterwards. I said, You know, you guys been doing the program like, yes, pooping every day doing great on miralax. I'm like, We're missing something here. Significant. And the next week, as fate would have it, I went to a meeting in Cincinnati Children's Hospital about in general and rectal anomalies because we deal with some of that as well in conjunction with surgeons. And they were showing me their bowel program as part of the course and saying, Look, you know, we get X-rays on everybody. Okay? And I was like, You know what? I'm getting X-rays because obviously asking the parents wasn't working. I remember that first clinic I remember, like yesterday, I had a kid, first kid showed up bedwetter. I asked, Are you pooping normally? They say he's pooping. Fine, I get an x ray. Just so much poop, just just a dense mass of poop in the rectum.

Mary: And this is just a regular standard X-ray that shows

Dr. Hodges: Yes we actually have a flat plate and treated that, not the symptoms. How are you pooping? Because, you know, we're giving you miralax until you poop daily. This kid was already pooping daily. I treated him until I got that mass gone was dry and I started curing people right after my neighbors.

Mary: You treated him for what? You treated him until he...

Dr. Hodges: For that actual mass like. So oh, and that my end point was a clean x ray.

Mary: OK.

Dr. Hodges: And so he did great, and I was started just treating lots of kids. I was treating neighbors, kids, kids from church. Just say, Take miralax do this, do that, and kids with no signs constipation. I was helping them out with the bowel program. So I thought, this is novel finding I was going to write this up and, you know, win a Nobel Prize or whatever. And I found out that this had been written about in the 80s by Dr Sean O'Regan. He had written that bedwetting plus a lot of other yeast related issues is due to occult constipation. You give them enemas every night and they get better, and I don't know what happened. People just don't like enemas. They stopped using them. They went to me, relaxed their end, goals changed and kids were getting undertreated. So we spent the past 15 years, I guess, now trying to spread the word.

Mary: Yeah. Well, and I remember somebody recommending your book, It's No Accident, which I think was written in 2011 or 2012, and I did a lecture on potty training. It was sold for many years. And so somebody gave me this book or recommended it. Soon after that was published because I didn't know. I mean, I knew that constipation could lead to bedwetting and that sort of thing. But really, this book was so much new information. I mean, it's like highlighted cornered. In fact, it's been so good that it really has been. One of the staples that I tell people about, it's in my 2021 book, but I didn't realize that you had you have a lot more information that's more updated in your Pre-MOP and your MOP book. So MOP stands for what?

Dr. Hodges: So the remember in the it's no accident book, the doctor that we found that had started, this was called Sean O'Regan, Dr. O' Regan. And his protocol is, we call it the O'Regan Protocol and we through our parents and our casework, we modify that. So map is to Modified O'Reagan Protocol.

Mary: Modified O' Regan protocol and in your it's no accident book. There is some things about enemas, but it is a lot of miralax. And in fact, in my 2021 book, when I referenced that, I said a lot of the parents that I work with, with kids who are on the spectrum are leery about all this. Miralax that it, you know, a lot of people think that it's not good for you and that sort of thing. So in your newest book, you do talk a lot about other options for laxatives, and you do talk much more heavily about suppositories and enemas, which. You say in your books, you know, people are like, that's really extreme. And as a registered nurse in the 80s and 90s, I remember actually giving enemas and the thought of giving enemas to a toddler or an older child or a teen does sound extreme. So how do you respond to that?

When and How to Start Treatment for Constipation:

Dr. Hodges: Yeah. So you know. A little I'm definitely open minded about it. If the child's been on no therapy before, then Miralax is a good first step, or other laxatives, it doesn't really. I just want to colon empty, you know, you could you could come up with a new way and I would be all for it if it worked. But we have a lot of kids with Encopresis which is poop accidents from overflow or they can't get on the right dose of miralax because they'll give some and nothing changes and they give a little more and they get diarrhea. That's all. Both those situations are there's a big clog at the end. And so just getting to the root of the problem. Enemas are much better at getting to the root, and I love how Dr. O'Regan is just pure scientist when we started this and you know, we surgeons, I guess doctors can be pretty analytical algorithmically. So he was like, Well, the problem is poop in the end of the rectum. The best way to get there is with an enema. That's a solution, you know? You probably remember this in the book. He treated his own son first. It wasn't like he was putting this to other people. So, yeah, it's just the shortest route to the caused the problem. So most people do fine with them. But you know, we've tried to adapt the protocol to give options that any family can can follow, whether they want to avoid miralax or used mirlax, or avoid enemas or use enemas. We can find a protocol to get the child empty.

Mary: OK. So since we're mostly speaking to parents and professionals in the autism world, I know firsthand that constipation bedwetting failure to potty train poop accidents is those are are huge, huge issues. I've done podcasts and blogs. You're my first expert to have on, so I really appreciate your time. And I do also want to say, since Dr. Hodges is a medical doctor and I'm a registered nurse and a behavior analyst, that everything that we're presenting here is for informational purposes only. And you really should work with the information in this book. And and he also has some Facebook groups we can talk about and we can link in the show notes. But you need to spread the word to your physicians and your health care providers to really get you on a plan. Also, as a behavior analyst, I know there's a whole lot more that goes into potty training than just treating constipation. And kids on the spectrum can have major problem behaviors and all of that stuff, too. Also, before we really dove into like constipation and babies and constipation in older kids and and how to treat it specifically, I did just show Dr. Hodges before we hit record this small pamphlet. It's called the Fatal Four, and it's by the Pennsylvania Department of Human Resources. So since Lucas is twenty five years of age, at the time of this recording, everybody that works with Lucas through his waiver has to read the fatal four. And basically, these are four conditions that can lead to death and are the four most common causes of death in adults with developmental disabilities, including autism. And they are aspiration, which is choking like, you know, eating food and then going into your lungs, and you could die from that. Constipation is the second, dehydration and seizures is the fourth. This is a big, big issue in the autism world. One, really, even for a child or adult who is fully potty trained like my son, Lucas is, he can't tell us if he went what the consistency of it is if his belly hurts. I mean, he might say belly hurts, but I mean, that would be very late in the game. And so for kids that are fully potty trained, that presents its own unique challenges because you can't easily keep an eye on things. Well, let's go way back to so I just want to emphasize how serious constipation is and that it's not just annoying, bedwetting and changing the sheets, which is very time consuming and causes a lot of stress to families. But it also can be deadly and lead to really, you know, very complicated situations. So let's go way back to like why is constipation increasing and when does it start in babies and what should we be looking for because we go the whole age range here?

Is Constipation Common and What Causes it?

Dr. Hodges: Yeah, you know, I think it's probably always been prevalent. I think we're probably doing better job picking it up now. My theory is that if obviously diet and activity exercise can influence it, but honestly, that human brain is just too smart for some good, there's no other animal or mammal that's going to purposely withhold poop. You know, they just just go. But humans, they if it feels uncomfortable and they can figure out that if they squeeze their sphincter. And put it off, it goes away. There you go, that's as easy as it is, it's as simple as it is and definitely runs in families or genetic traits, like whether it be personality traits, you know, the whole concept of being anal retentive, whatever it is, some people are just more likely to withhold than other people. And you see this right away and babies are born. The poop is very much it's, you know, they're just on breast milk or formula comes out like mustard seeds, you probably remember. But even then, there's some discomfort. It's the sensation of having to poop, you know, out of the womb. You know, you're not pooping in there and then you're all sudden you have this weird sensation, so they don't relax. It's called dyskinesia, and it's a transitory phrase where they just face where they get through it and they start pooping normally and typically. Then you'll see babies in this kind of nice in-between zone where they're pooping in diapers without even, you know, you hear it. You can't tell from their expressions that they're doing it.

Mary: So when does this little phase go when they start doing something different?

Dr. Hodges: Well, I just if dyskinesia starts, it starts at birth and then you start the first couple of weeks, it's gone. And that's the kids that used to tell you to, you know, put some Vaseline on their bum or use a thermometer to kind of force it out. No, my oldest had it and I was like, what she straining for and when to put the thermometer down there? And it just liquid came out. There was no, there was nothing actually constipated there. And after she got used to going, it was fine and she didn't have any issues. But then, you know, you have other things and that typically is changing diet. So if you go to a different formula or a different feed, adding rice cereal or something like that can do it. It was one of my kids adding table food for sure. Dairy for sure. Just change the consistency and think about it. You feel something different. You start holding and that's all. And it just snowballs. And then sometimes not only is it getting firmer poop, but it's getting looser poop and then going back to normal. So an antibiotic treatment that which gives them diarrhea, they feel discomfort from that. And then once the poop firms up, it starts it. So they kind of phase like that that makes them uncomfortable. Pooping can be all it is all the trigger. You need to start this kind of cycle of constipation and couple things on that topic. Important number one is once it starts and they're prone to it, you need to keep an eye on it because it's not like a week phase. You know, it's not like you're going to give them miralax couple days and they're fixed. It's in their head now, and they need to be going regularly for a while and it doesn't. The second thing is that it's a chronic therapy. It's some kids that are very prone to constipation. Parents will get them more relaxed, get them through the phase. And then when I stop it, they worry like, you know, are they addicted to me? Relax, or why can't they poop on their own? And it's just that this child has now learned that it hurts to poop. And so they need extra help and keeping it soft so that doesn't hurt them is all they need. But they may need that help for years until they're old enough to know that when I need to poop, I need to let it out. And it could be, you know, some people never get there, but it could be a few years.

Mary: Yeah. So each in your both your books and I, I haven't finished them both, but I get the idea that you believe that everybody, every child and adult with or without autism should be pooping every day.

Should Your Child Be Pooping Every Day?

Dr. Hodges: Yeah, you know, I definitely think that if you're eating every day, you should be pooping every day, and that's pretty consistent, long the animal world. Every time I make a claim like that, I kind of regret a little bit later because I have parents really going all out to get a kid to poop every day. And maybe if they poop every other day, they would be fine, you know? So I think pooping every day is a good goal. But really, you know, the child has to have a sign that they need help to be really aggressive with it, you know, belly pain, hard bowel movements, accidents. If the child is completely healthy, just living life, doing great, no issues. Pooping every other day is not a big deal, but you definitely want to keep an eye on things and be aware. You know, I think going from being aggressive with them, pooping too much and the opposite where you're not, you don't even know how I think. Oops, there's some kind of happy medium in there where you're just keeping an eye on things and making sure things are regular.

Mary: Yeah. So changes in diet, being on antibiotics, having diarrhea and then firming up, those can all be kind of critical junctures where a child could start to get constipated. And it's just not normal for constipation to occur, like to occur. I remember, you know, people I knew were like, Oh, my kid poops ever and not on the spectrum. He only poops every seven to nine days.

Dr. Hodges: Oh, it's insane. Yeah, I think it's the most common medical condition in children with functional constipation, right?

Mary: So if so, I had a, say, five year old, potty trained child or even a baby because this was a baby's not going for seven days. So if I have a baby that hasn't poop for seven days, what should I do? Should I go to my pediatrician? Should I ask for an x ray? Should I try to clean them out myself or depends?

Dr. Hodges: Yeah. For the infants, it's tough and I'll say why it's there's this thought, and I honestly have not pin them down on this. But there's a thought among the attractions that if you're breastfed right, if you have this pure diet breastfeed, then you're not making enough poop to poop. But once a week, you know, and that's a study that needs to be done right. Maybe like ultrasound their rectum and see if it fills up or they're not going. So again, I don't. I'm a big proponent of aggressive treatment constipation, but I have to have a cause, you know, because I don't want to be just tracking kids down the street saying, you know, you need miralax. So in the babies, if they're otherwise completely healthy, no other issues and their on breast milk. Talk to your patrician. If they think it's OK and you're happy with that, then it's fine to kind of slow roll it. But if you have a child that is straining to poop, having large bowel movements, definitely having difficulty like pooping is in their brain, you know, it's a stressful situation for them. Hiding the poop is a big one. People think they're just hiding because they're shy. It's a sign of constipation. And I would definitely talk to your patrician about getting a treatment for that. And I think, you know, most kids go through a phase like that. If you if you think back to it and just keep track of, you know, be involved, you're involved, your kids diet and their exercise and all that involves their toilet habits as well. And take a look and see what sounds weird, but it's really important if they're putting out the most common sign we hear from parents of that we know to be constipation. The parents just mentioned in passing as, oh, just the biggest bowel movements are just huge, you know? So that's a that's a bad sign. And I know I say I don't want to treat things unless a child is having problems, and I definitely believe that. But if you have a child that's severely constipated, they may develop issues, right? So you don't want to completely be out to lunch. If they're having some signs just because they're happy and healthy, you want to keep tabs on things because they could develop some issues later on. And I don't think it's healthy to have a hugely dilated full colon period just for adulthood and so forth. So I think awareness is the key. You know, you figure out the details by talking to a patrician, but if you have a child that's having trouble pooping, they don't have to. And if they're having other accidents or other issues, we can definitely fix this.

Mary: And in your books, youdo say that potty training or really heavily focusing on potty too young can also be a critical junction point for kids to withhold and get constipated.

Dr. Hodges: Exactly. You know, I got a little sideways to slow the elimination communication people just because they really promote and I'm not for pollution like diapers. I know that they fill landfills, but I think it's definitely unhealthy to train too early and you have to look at what are we doing, you know, people that try to get out of diapers too soon or probably just training themselves to respond to the child's urges and signs the potty training. And this is from Dr. Regan, a quote he told me, I think this is 100 percent accurate. It's a physiological process like walking or sleeping or, you know, being hungry and eating. You can't force saying, this is right. You can't make your child's sleep. You put it in the right environment, you can't make them crawl or walking fast and they're going to you can't make a child potty training any faster than they were going to, although it can be delayed if they're constipated because they lose control. So I've seen a child younger than three, thats really ready. And I don't see many kids older than four that shouldn't be ready. So for me, between the age of three and four, if they're developing normally and I have no other conditions, obviously, then that's a good age of potty train.

How Does Autism or Developmental Delays Effect Pottying?

Mary: Yeah. And I do want to make a caveat there, because most of the kids that the listeners are, you know, either their own child or their clients. They are developmentally delayed and that adds a whole nother twist to it. And so from a behavioral point of view, I am all about tearing up the potty early like to just to make it part of the, you know, we sit on the potty. We don't even have to go. We just sit on the potty in the morning and maybe before. And we watch their older brother. And I'm also a huge proponent on the boys should sit on the potty until they're fully bowel trained because I hear it all the time. You know, an older boy is pee trained, but not poop trained. And almost always, I'm like, Are they sitting on the toilet to pee? And they say, no. And so, you know, and one of your books you talk about, like scheduled sits right after breakfast or right after dinner when you are more likely to poop or first thing in the morning. Physiologically, you're more likely to poop. But I do think that for kids with autism waiting too long to introduce a potty as this is where we sit, just to relax is also a problem because then they might be super resistant on top of it.

Dr. Hodges: That's an excellent point. You know, my the one, there's no harm in introducing things. You don't want to pressure them to hold it. And that's the thing. Number two, the one downside of delayed potty training or later potty training is that some kids just get too comfortable pooping in pull ups and toilet avoidance for pooping is super common. So typically, the kids will pee on the potty and then they won't poop. But although you know the story of the child that will just be completely dry, but come home and ask for diaper poop in or pull up is is so common, actually. And there's there's protocol set up to treat that issue.

Mary: How do you treat that issue?

Dr. Hodges: There are two ways to treat toilet avoidance. One is with this. It's in the book called The INS and Outs of Poop. It's kind of this graduated just kind of movement towards the potty that actually.

Mary: Yeah, there you go. My whole, my whole potty training collection. Oh yeah,

Dr. Hodges: It's a great I've given a lot of families. It works well. Basically, you say, OK, you can poop in the pull up but you have to poop in the bathroom. OK, I'm going to pull up on, just poop on the toilet, that kind of thing. And I love the story, has the girl that will poop on the toilet. But she has to put the diaper on first because they had to cut a hole in the diaper and she hadn't pooped anywhere near the diaper. And so long they just kept the same one. And so it was like a belt. She was like much older, but she needed that. And so it just shows you how much thought people put into something.

Mary: Yeah. And I had another approach like where, you know, you can have the diaper, but you have to stay in the bathroom. And that gradual fading of the diaper does tend to work. However, I will also say, especially after reading your new information, is that the child is probably constipated if they're able to hold it all day and ask for a diaper and...

Dr. Hodges: They're not going on time, right?

Mary: And you know, they're they probably could also benefit from laxatives and enemas, which you know, is tough because if you can't even get a child to sit on the toilet easily. So I have a lot of advice about pairing and desensitization, but if you can't get them to do that, how are you going to be able to have them calm and comfortable enough for you to insert something into their rectum?

Dr. Hodges: Yeah. The other approach which gets to that point is the Dam approach and Dr. Dam that recently passed this past year had an approach Encopresis. And so if you need to force the issue, for example, like if you have a kid that's just too comfortable pooing in the pull up, and just has no interest in just not going to go, not going to go anywhere but the pull up. He has this protocol that was originally designed for Encopresis treatment, but he basically has the space the child can move in confined to. Typically, you're in a bathroom, has no bottoms on. So the child doesn't have any kind of perceived protection because for whatever reason, kids will poop in underwear before they'll poop on the floor, you know? Now, some kids might poop the floor, but there's a barrier there. There's extra barrier, mental barrier, and then it gives them a really high dose of ex-lax. He was his his dose was six ex-lax squares. And so then it becomes like this kind of standoff. So these kids that are like would never poop and potty ever, they've been exposed. The party, like you talked about, they know what it is. They don't like poop in there to give this ex-lax. They have no underwear on their right next to the toilet, and all sudden the urge hits them. And they do sit on the potty typically at that point, because it's like you have to decide there's no it's coming on, and the brain knows immediately that there's no stopping it. And so they tend to poop on the potty, and that's just kind of like the sink or swim method. That sounds extreme, but I've seen it work in certain cases very well.

Mary: Yeah. And and even in I mean, my first book, I mentioned this Richard Roxburgh. Richard Fox is a pretty famous behavior analyst, and it's called toilet training in less than a day, and it was written in the 70s early 70s. Well, there's actually a punishment procedure in here that once they have an accident, you take them to and from the accident. Unfortunately, yeah. Unfortunately, I, you know, a lot of behavior analysts still kind of ascribe subscribe to some of these methods. And even in my first book, I do talk about how we did use positive practice, which is a punishment procedure which I do not recommend. We used it to get Lucas poop trained after I literally called the reports on the phone and asked him now. Now, you know, 15 years later, since writing a book, I am all about a positive approach and all about treating the medical underlying condition, especially constipation and other weird things that could be happening and to never punish or stigma, you know, stigmatize a kid. Or so we want to be as gentle as positive as possible. But at the same time, we do need to treat these kids. In some way, because potty accidents, I mean, you've said it a couple of times and Encopresis is poop accidents and Enuresis is pee accidents, and it can be daytime or nighttime. It's extremely stressful for the child and the family.

Dr. Hodges: Yeah, that's a great point. So you do not want to punish a child. This is a very common cause of abuse. It's frustrating for parents that aren't informed. They think the child's doing it on purpose or just not being responsible. And so it causes a lot of abuse. So we don't want that. The alternative is not ideal either, just ignoring it because it could be as simple as constipation, or it could be a real medical condition. They can have a spinal cord disorder. They could have a congenital anomaly. So you need to have it evaluated and treated. And if it's just constipation, hooray, we can work through that. But you don't want to ignore it because it could be some other issues. And yes, the quality of life effects of this, of these problems on children are significant. They've been published extensively.

Mary: Yeah, yeah. And this fatal four, I mean, constipation actually be so serious that it leads to obstruction, needing surgery, and death.

Dr. Hodges: And you don't want to get to that point, exactly, there's usually warning signs that we could talk about and not just the kids, I think, and I'm sure are going to get into this is that a lot of these problems are ignored because they're blamed on the autism. Well, yu know, they're not potty trained yet, it just developmentally delayed or they just can't do that. In reality, much like kids with ADHD, there's a high rate of constipation, which then manifests itself as these accents.

Mary: Mm-Hmm. Yeah. And one one of the things and I mean, Dr. Richard Fox is a brilliant man, and he was doing research in the 70s. So it does have, you know, some punishment and things like we did that now are not acceptable. But you know, he he was a big proponent of any child by the age of five and any cognitive ability level can and should be potty trained.

Dr. Hodges: I agree with that.

Alternative Treatment for Severe Cases of Constipation and Accidents:

Mary: And I agree with that, too. And so when I hear of older children, teens or even adults who are not potty trained and it's not that the parents and the professionals haven't really tried, but I do agree that just talking about constipation, not just talking about it like. X Rays, miralaz or other laxatives, enemas or suppositories like it's not enough to go well, we have tried, we've done this or that, or we tried to take him to the bathroom. Yeah, you know, every hour on the hour, it's like, Well, if that's not, you said something in one of your books, like if any part of this is definitely not working, you don't want to just keep doing it.

Dr. Hodges: Yeah, 100 percent if they're behind the eight ball because they have no control of their bowel or bladder or both, because the constipation, any kind of behavioral therapy is going to fail. And you know, in a lot of these things are appealing to the mind like, OK, well, they're not they're not having this potty dance or having accidents. They're waiting too long to go pee. And so I'm going to have them pee every hour or every two hours or every 30 minutes. And if I wish that worked. But what ends up happening is that kids sit there, they don't have to pee. They get up and have an accent. And one thing that really had an impression on me is, in some severe cases, we will do Botox because it can really limit the effects of the colon on the bladder or block them. So bladder is not overactive. Independent of the poop kind of makes the bladder ignore the signals from the poop.

Mary: So what do you do with Botox?

Dr. Hodges: You inject it in the bladder.

Mary: In the bladder to prevent accidents, even if they're related to constipation?

Dr. Hodges: Because the reason the accidents are happening is because the dilation of the rectum is causing a nerve firing that's setting off to boarding and that will block that signal. It's kind of this, you know, just kind of how much signal, how much blockage you have, kind of thing. And so in severe cases, I mean, we always work on the bowels, but thats a kind of last resort is expensive and it doesn't last. So it's not like a perfect thing, but it can help some kids. But the reason I mentioned is there's an anchor. I had a kid that was these parents like, this kid will not go to the bathroom, he will not go to the bathroom, he will not go pee. We talked to him. We've tried everything. We've tried bribes. We've tried everything, he won't pee. We did the Botox, that kid. He had a good dose. It kind of, you know, it took it the right dosing, right? Because there are a lot of variables. The next week, he was peeing completely, normally with zero behavioral changes. So with that, what I've understood is that the urge to pee like it's not like you were, I had some special gift because we can go pee when we need to. Our brain, tells us we need to go pee. But if you're if your plane tells you got to pee and it fires off 100 too late and you can't make it. So I always tell parents that if you had your child's bladder, you would have accidents, you know? And if we fix the bladder, he couldn't hold long enough because you I mean, you wouldn't be able to hold to long because eventually you're forced to go pee. Much like potty training is a physiologic process. Just going to pee on time is a physiologic process. So if your eye right now tried to hold our pee till we had an accident, we wouldn't. Our brain wouldn't let us. It would make us go to the bathroom eventually because it just becomes annoying. And so there's some delay in emptying, of course, because they hold their poop in. But when they're sitting there and pees on themselves or poops on themselves and didn't even know it, there's more to it than not going to the bathroom.

Potty Training, Constipation, and School Policies:

Mary: Yeah. So you talk a little bit and I talk a little bit my stuff about the policies of daycares and preschools of, you know, peeing by three, a potty trained by three, no accidents or a couple of accidents for a set amount of period. Otherwise, you get held back, kicked out, not promoted to the next class. I even had a client who had to pay a premium to kind of have her daughter go to the next class, but then have more support there in case she had to pee. So and even schools, you know, kindergarten, first grade, you know, they have very restricted like punishing kids for needing to go to the bathroom. So can you just talk for a minute about that?

Dr. Hodges: Yeah. I tried to take into consideration everyone's perspective here, you know, because I'm not running a school or daycare, and I figure it's difficult. But as long as they have the understanding, so I don't want the daycares or schools, to think the parents are being lazy and just showing up. Here's a kid that does not potty train again. As we talked about, if a child is old enough, it will pretty much potty train themselves if they have the exposure to it like that you talked about. So if they're not potty trained, there's a problem. And so number one point is I'd like to pick this stuff up early and so no one, would have to deal with it. You know, we could just treat these kids very early before they got there. But I do think it's a parent's forcing a child to potty train before they're ready before their three in child obviously doesn't have the maturity just to get in a daycare. That's a bad thing because you're forcing a process. And again, it's a process we just mentioned several times you can't force. So I try to help parents get notes or doctors support to allow the child to go at their own pace schools. Another thing you know, I know they need to keep track of the kid's school safety's a big deal. But I. I think there's definitely ways that you can develop systems that keep track of the kids, minimize, you know, I don't know, I'm kind of running around the halls but allows them to go the bathroom whenever they want and the behavior that we've heard. I'm not saying kids should have free reign and just run around the bathroom whenever they want, but to have them run laps or pay money or whatever to get access to the bathroom, which we've seen reported is it's beyond the pale. So I think we can all get together. And if we understand that look, kids train at their own rate is a physiologic process when they're ready. And if they are having access to have a medical condition and holding in their poop, especially poop, you know, which no one likes to do in public can lead to problems. And I think we get around board and come up with plans that would help these kids get access. I was just talking to a pediatrician today and wish we had, you know, private restrooms everywhere, right? Like in schools, that's most kindergarten classes have them. But beyond that, they don't because they're so much a barrier for kids to poop in public. It's tough.

Mary: Yeah. And and one other thing that before we leave the school is also once a child with autism, is toilet trained and is spontaneously asking to go to the bathroom. It's really important that we don't put them on a schedule. So I was always very big proponent of, you know, when when Lucas would switch teachers or go to a new grade or go to a camp or something like, I don't want him going every two hours or every hour and a half with the class I want him to request because you can get a kid that's potty trained and spontaneously asking to revert back to having accidents because they're put on a schedule. So also something to keep in mind, especially for kids that are new to toilet training and new to asking, which is a hard thing for a lot of kids. So I assuming and it's in your books that keeping an eye on your child's poops and having school home communication about pooping and peeing is really an important thing for.

Dr. Hodges: Yeah, I would, you know, a part of Open House, I would check the bathrooms out. Where are they, where they look like, what's the bathroom policy? Are they clean? Do the doors work? Is there toilet paper. These are important things because if your kid shows up there doesn't feel comfortable going, then you're going to. You could potentially have some problems.

Mary: And you also have in one of your books a letter to use to kind of be like, my child has some constipation issues and they need to be given free access.

Dr. Hodges: So I write a lot of those letters. Yeah I write a ton of those letters. That's important, you know, and I think, you know, some of its restrictions, some of its kids aren't comfortable doing it. So I think we as a society, we need to talk about this more and pick up the importance that you know, we talk so much about. You need to exercise, you need to eat right, you need to do all this thing. You brush your teeth and floss. No one ever says you've got to poop when you feel it, you know, it's just kind of ignored.

Mary: Yeah, yeah. So with the both of the pre-mop book and then the pre book is just for kids until they're potty trained.

Dr. Steve: That's the pre potty training constipation.

Mary: OK. So even if you have a child who's older with autism chronologically, they're developmentally up there until they're fully potty trained, right?

Dr. Hodges: Yeah. And you, you know, I'm going to hedge that a little bit because if you have like a 10 year old that wasn't potty trained, you're probably going to need to be aggressive. So it might be better to do a full mop because I would say, OK, should definitely be potty trained. So since we're so far past it, let's treat this as accidents not as never potty training. That makes sense?

Mary: Okay, so there's two books they're pre mop up and that is for kids that are babies up until they're potty trained, except for if you have an older child, like if you have a five or six year old that's never been potty trained.

Dr. Hodges: If you just want to regulate their pooping to potty train. Exactly.

Mary: And an older child or teen or...

Dr. Steve: Kids that are having accidents. Yep, we actually have a book out for teens now, too. Yeah, just to make them feel a little bit tailored to them because I know that sometimes they don't get on the Facebook page, they expressed. They didn't like being clumped in with the younger kids. Yeah.

Mary: Yeah. And we're going to talk about the Facebook groups in a second. And in the pre-mop book, you do say that young children, babies can use, you can use suppositories instead of enemas.

Enemas and Suppositories:

Dr. Hodges: Yeah. So there's a liquid glycerin suppository made by plexus for ages two to five, but you can take a little slivers. You can talk to your pedatrician about it. You can take a look at the solid gross response force, get a little sliver of it, put it in there, just a little stimulant to get things going. Okay? Especially if they're trying to get out a large kind of lead fragment. We call it urology. A big mass is blocking everything. You know, it's going to get it out there and there's lots of things you can do. You can use Vaseline as lubrication. Some kids are. Put in a warm tub with baking soda just to relax the muscles to get past that, that kind of stuck part.

Mary: And this is just like a question I have because I, like I said in the 80s, gave enemas, so I really don't know how to do that now. But, you know, do they sit on the toilet while you insert that? Is it? Do they lay on the bed and lay there for a while and then go, like, how does that work? Like logistically?

Dr. Hodges: Yeah, the best way to do it. We just kind of keep it simple is have them lay on their left side because, you know, the sigmoid goes on that way and put the enema there on the floor, in the bathroom. I mean, you could do it anywhere, but I don't want to be responsible for messed up carpets. So I say next the toilet.

Mary: So you put a waterproof thing down on the bed.

Dr. Hodges: You're not going to have something come right away, but you have time. It's just the first one. Maybe just to close. You put it in and just tell them to hold it so they have to poop. And typically the kid will get up and be like, Oh, I got to go sit on the toilet, poop. It's pretty immediate.

Mary: Yeah. All right.

Dr. Hodges: Plenty of lube. That's the key.

Mary: Yeah. OK. So I mean, obviously, that's for some child that's going to tolerate that, which, you know, is probably a little farther down the line than for most typically developing children who can understand that. But at the same time, I do know families with kids that aren't constipated, that do clean them out with enemas and suppositories and laxatives, but they only clean them out once a week or once a month. And so this would probably be, you know, an adjustment for sure. And a new protocol. But it's not like out of the question, like if you have a child that doesn't poop, that's constipated, you're going to need to do something to get the poop out. And I like the idea of talking to your pediatrician potentially about getting an x ray just so you and the child and the pediatrician all know that this is a blockage. This is a lot. And because I remember your first book and I don't, maybe I don't have the statistics, right? But like, you had people coming to your clinic in North Carolina, and 90 percent of the parents said their child was not constipated and 100 percent of them were.

Dr. Hodges: Yeah. You know, the only reason I get X-rays anymore other than to monitor progress is to commence to get the family on board because I'm already, you know, I know what's going on and is effective in doing that because when they see all the poop, they're really aggressive. And I think a couple of points on enemas. Number one is you never know how they're going to react to it. Try it so you can try it and use our techniques. Second, if you if you think of this as a medical condition, I think it changes the analysis a little bit like if you know, God forbid if one of my children had some severe medical problem, but I had a cure. But I care was an animal. I would definitely do it, you know, so I don't. I think because people outgrow accidents or accidents aren't really seen as a medical condition, it becomes a little more difficult. But if your child had, you know, pick a pick a horrible disease that would be cured with an enema, I'm sure parents would do it.

Mary: Yeah. And for very young children, then you could do a suppository. You could even probably do that with them on the toilet or bending over or something on your lap. It's easy. Yeah, on your lap and....

Dr. Hodges: Put them over kind of like that, you know? Yeah, kind of bum up.

Mary: And I mean, we've done suppositories when we've had babies that have had fevers and that sort of thing. I like your idea of like, think of this like a medical problem. Think of this as something you have to solve because something I read in in your book is that if a nine year old is having bedwetting and constipation, the chances of them being, you know, a teenager with constipation and bedwetting is very high.

Dr. Hodges: Yeah. And you know, you don't want to be stuck as it. You know, that's what happens. They're waiting. Outgrow it. Next thing you know, 10, 10, 15 years go by and then, you know, they're getting ready for college. And it's just and I can't promise that this does or doesn't happen, but there's something to be said. If your colon dilated abnormally for years. That's definitely worse than if it was dilated for a shorter time, you know, so 15 years dilation is more difficult to resolve and just five years or three years? If that makes sense.

Mary: And when the autism population, the older your child gets, the bigger they get. The more aggression can happen, the more physically, you know. The earlier we can get to this, the better. And like I say with ABA, it's never too early and it's never too late. So whether you're listening and you don't even have autism in your world, we really have talked very little about autism. I talked and but it does complicate things. But at the same time, it's the same techniques will work.

Dr. Hodges: Yeah, my synopsis, the main thing I want your viewers to get is that these issues, whether bedwetting day wearing accents, delayed potty training are all written off as part of autism. Oh, they're just they have it's an autistic child. They'll train later. And so we have more cases of missed constipation, I have more cases of misconstipation, in autistic children and more cases of severe constipation in autistic children. So I would say that the same rules apply to them as it would apply to any other child. If they can't potty train, if they're having accidents... Get the x ray, the x ray will likely show them full or get evaluated by a doctor. You know, maybe to find something else if they find the constipation, you follow our protocols and they should do great, right?

Dr. Steve Hodges' Clinic, Books, and Facebook Groups:

Mary: And you have a clinic in North Carolina? I don't know do you accept kids with autism?

Dr. Hodges: Oh yeah, they just come because they have these issues, you know, and they need help. Yeah, yeah.

Mary: Yeah, I'm sure you would want people to try the method that's very well outlined in your pre mop and mop book. And then you also have something you have three different Facebook groups that are paid Facebook groups for parents or professionals to join. Is that right?

Dr. Hodges: Yes, we have a parents only page. It's free. We have a just generalized information page. It's free. Then for the paid group, we have a teen group because they, you know, they want their own group, the traditional mop group and then the pre-mop group. And I'm just come off a busy weekend, I have to check it today. I think to catch up, but the yeah, I think it's provides privacy. It provides kind of a, I'm not the only one in this kind of mess, a feeling and advice from other parents, you know, as a scientist, this, you know, I'm used to doing studies and kind of collect data over time, but the internet's pretty amazing. I mean, we can we've learned so much just from the real time feedback from the parents and modified protocol quite a bit just from their feedback.

Mary: Yeah. Which is awesome. And the website is...

Dr. Hodges:

Mary: We'll link that in the show notes as well. And it's been a fascinating interview for me. I have followed your work for over a decade, so I am really excited to talk with you. I'm sure you are going to definitely be an episode where I'm constantly giving out the episode number. So thank you so much for your time before I let you go. I always like to end my podcast the same way. I didn't warn you with this, but as a very busy medical doctor, as a father of three girls, part of my podcast goals are for parents and professionals to be less stressed and lead happier lives. So do you have any stress reduction tips for everybody listening or self-care tools that you can recommend?

Dr. Hodges: Yes, self-care. I think getting plenty of sleep, you know the basics eating right, exercising the gym and then it's so funny. I, my wife jokes like, you've become so much more religious. I think family stress is just like, like, Oh, you need somebody else to kind of lean on. And so I'm Orthodox Christian, and that just the teachings have helped me a lot. And so I hope that I can be a better father and husband using those techniques.

Mary: Awesome. All right. Well, thank you so much for your time and take care.

Dr. Hodges: Thank you so much.

Mary: If you're a parent or an autism professional and enjoy listening to this podcast, you have to come check out my online course and community where we take all of this material and we apply it. You'll learn life changing strategies to get your child or clients to reach their fullest potential. Join me for a free online workshop at, where you can learn how to avoid common mistakes. You can see videos of me working with kids with and without autism. And you can learn more about joining my online course and community at a very special discount. Once again, go to for all the details, I hope to see you there.