Teachers’ Knowledge of Normal and Abnormal Elimination Patterns in Elementary School Children

INTRODUCTION

About 10% of 5-year-old children and 5% of 10-year-old children have urinary accidents during the day, according to the National Institute of Diabetes and Digestive and Kidney Diseases (2004). Unfortunately, some of these urinary accidents occur at school, resulting in the child being embarrassed, and being taunted and teased by classmates. Social and psychological devastation may be the consequence of this potentially preventable circumstance. In one study, children ranked wetting their pants at school as the third most catastrophic event that could occur, behind only the death of a parent and going blind (Ollendick, King, & Frary, 1989). How often are children encouraged to go to the bathroom during the school day? How are accidents at school handled? Are teachers aware of urologic problems that children may face? These are some of the questions asked in a survey of elementary school teachers regarding their perceptions and practices related to toileting habits in elementary school children (Cooper, Abousally, Austin, Boyt, & Hawtrey, 2003).

LITERATURE REVIEW

Chen, Chiou, and Sheu (2000) looked at the prevalence and factors related to the postponement of bladder emptying among 1st-to 5th-grade children in Taiwan. These authors found that postponed bladder emptying was prevalent, with 64.1% of students reporting postponing bathroom breaks. Symptoms of cystitis were reported by 18.4% of students; cross-tabulation showed that postponed bladder emptying was significantly correlated with symptoms of cystitis. In this study, students and their parents disagreed about the importance of bladder emptying. Students regarded playing or being in class as more important than going to the bathroom. Conversely, parents believed that bladder emptying was more important than playing or studying. The condition and accessibility of bathroom facilities were regarded as lacking, with students indicating that they did not want to use the bathroom because of smell, distance, filth, or having to wait in line. Chen and colleagues (2000) suggested that administrators, teachers, and school nurses could affect student attitudes by teaching them about basic hygiene and the importance of good bladder habits. Sufficient breaks in student schedules as well as adequate and accessible facilities should be a goal of school health professionals.

Kajiwara, Inoue, Usui, Kurihara, and Usui (2004) studied the micturition habits and prevalence of daytime urinary incontinence in Japanese primary school children. The authors found that the overall prevalence of daytime urinary incontinence in primary school children is 6.3%, which gradually decreases with the child’s age. Increased daytime frequency, history of cystitis, and infrequent bowel habits are significantly related to daytime urinary incontinence. The authors suggested the link among daytime urinary incontinence, daytime frequency, urinary tract infections, and constipation deserves more study.

MATERIALS AND METHODS

As reported above, Cooper and colleagues (2003) mailed 1,000 surveys to public elementary school teachers in Iowa to determine their practices in student bathroom use and their school’s bathroom facilities. The Iowa Board of Education provided a random sample of 1,000 mailing labels representing teachers from kindergarten through 4th grade and higher, from both large and small school districts. This Institutional Review Board–approved survey consisted of 21 questions followed by multiple-choice answers. Respondents also had the opportunity to elaborate on their answers in essay form.

The questions were divided into four parts. Part I consisted of questions about the privacy, cleanliness, and safety of bathroom facilities. Part II elicited perceptions regarding normal and abnormal student bathroom habits and inquired about the teacher’s practice of allowing children to take bathroom breaks. Part III was devoted to the management of bowel and urinary accidents. Part IV asked for demographic information about the respondent and the school, including the number of years teaching, grades taught, whether or not a school nurse was present in the school, as well as class and building size. In this section, the survey queried teachers as to whether they had ever received information about abnormal voiding or bowel problems in children or if they were familiar with anyone specially trained to treat children with abnormal voiding or bowel problems.

Four hundred and sixty-seven respondents returned surveys. Results were analyzed relative to grade taught, years of teaching experience, class size, and building size. Grade taught was characterized as kindergarten, 1st, 2nd, 3rd, and 4th grade or higher. Teaching experience was defined as less than 1, 1 to 3, 3 to 5, 5 to 10, and more than 10 years. Class size was defined as less than 15, 15 to 19, 20 to 24, or 25 or more students per class. Statistical analysis included chi-square test, t-test, Kruskal-Wallis test, and the Wilcoxon rank sum test.

RESULTS

The majority (70%) of the respondents had taught elementary school for more than 10 years; only 3% had taught elementary school for 1 year or less. Teachers from each grade level—kindergarten, 1st, 2nd, 3rd, and 4th and higher—were fairly evenly represented. The median class size was 20 students, with a range of 4 to 70 students. The median number of students per building was 250, with a range of 12 to 900.

The results from Part I identified boys’ bathrooms as less private and slightly less clean, with a greater likelihood of bullying or teasing to be present. Teachers described all or just one private stall present in 34% of the boys’ restrooms. This compares with teachers identifying 10% of the girls’ restrooms with no or just one private stall. Cleanliness was always present in 35% of the boys’ restrooms, and in 48% of the girls’ restrooms. Teachers reported adult supervision in 66% of the boys’ bathrooms and 67% of the girls’ bathrooms.

A majority (86%) of the respondents considered bathroom habits as abnormal when a student urinates every hour or more than once per hour. Just 10% of the respondents considered voiding every 2 hours to be abnormal. Most teachers (80%) reported having set times for students to visit the bathroom, but 40% allow children to go to the bathroom at any time. Of those who have set times for bathroom breaks, 39% reported only those students who volunteer go at those times. Thirty-one of the teachers ask students to wait to go to the bathroom, and 80% of the respondents allow only one child to go to the same-sex bathroom at a time. Forty-one percent of respondents thought boys visit the bathroom for reasons other than elimination, and 38% of respondents thought girls visit the bathroom for reasons other than elimination.

When asked what they would do if they suspected a child has urinary frequency, the majority of teachers (82%) indicated that they would report this to the child’s parents. The proportion of the teachers reporting urinary frequency to parents was highest in kindergarten (93%), 1st (84%), and 2nd (89%) grades. Those teaching 3rd and 4th and higher were less likely to report this condition to the child’s parents, at 70% and 69%, respectively (p < .001).

Only 17% of the responding teachers suspected an underlying health problem in a child with abnormal urinary frequency. However, those teachers with more than 5 years of teaching experience (59% of respondents) were significantly more likely to mention it to the school nurse, compared with those teachers with less than 1 year of teaching experience (36%), 1 to 3 years of experience (36%), or 3 to 5 years of experience (43%; p = .023). Teachers of classes with more than 20 students reported that they would mention abnormal urinary frequency to the school nurse more often than teachers with classes of fewer than 20 students (80% versus 43%; p = .001).

The majority of teachers (92%) reported having encountered a student who had wet his or her pants. Of those who had not, most were teaching 3rd grade (14%) or higher (20%). Those teachers with less than 3 years of experience were less likely to have encountered a child with wet pants.

Twenty-nine percent of teachers surveyed had never encountered a child who had a bowel movement in his or her pants. Of the teachers surveyed who had taught for less than 1 year, 57% reported that they had never encountered this problem, compared with 22% to 38% of those teaching for a longer period of time (p = .054). Fifty-eight percent of those teachers who had encountered a child with soiled pants mentioned it to the child’s parents. Only 15% of teachers suspected an underlying health problem when they encountered this situation. Those who taught kindergarten had more often encountered a child who had a bowel movement in his or her pants, with only 8% of kindergarten teachers reporting that they had never encountered this situation. Twenty percent of 1st grade teachers reported never encountering a child who had a bowel accident in his or her pants, compared with 32% of 2nd grade teachers, 45% of 3rd grade teachers, and 48% of teachers of 4th or higher. Most teachers (67%) reported having encountered a student who was reluctant to let them know about having had a bowel or bladder accident. The proportion of those teachers reporting having encountered this reluctance in children was significantly higher among those teaching kindergarten (77%) or 1st (74%) or 2nd grade (72%) than those teaching 3rd (53%) or 4th or higher (47%; p < .00001).

Potential sampling error and the potential for misinterpretation of the questions were limitations of this study. The percentage of respondents was slightly less than 50%, and a sampling error may have skewed the data. Those surveys returned reflected an even distribution of teachers across grade levels, making this error unlikely. However, there may be other differences between those teachers who did and did not return the survey that may have skewed the data. Some respondents may not have provided answers to the questions that do not reflect reality despite the promise of anonymity. All questions in the survey were answered uniformly and without apparent misunderstanding.

DISCUSSION

This study was prompted by comments heard from children who were being treated in our pediatric urology clinic for voiding dysfunction. These children and their parents often complain of restricted access to the bathroom at school. They also complain of a lack of privacy or poor sanitation, and children often report avoiding use of the bathroom at school for these reasons. The results of this study point to a lack of knowledge among the schoolteachers surveyed about the promotion of healthy bladder habits in children and when to refer the child for evaluation of possible health problems as a cause of incontinence.

Children spend nearly half of their waking hours at school, yet teachers have received little or no education about normal elimination habits in children. Bathroom facilities are often lacking in privacy, safety, cleanliness, and accessibility. When accidents do occur, very few teachers suspect an underlying health problem. The opportunity for children to learn good bowel and bladder habits is often missed at school. Poor habits and a lack of understanding about normal elimination patterns place children with voiding dysfunction and other elimination problems at risk for the devastating consequences of teasing by peers.

There appears to be a learning curve among teachers with respect to the identification and significance of abnormal toileting habits among children. This curve was demonstrated by the fact that teachers with more years of experience were significantly more likely to report these findings to a school nurse. Teachers of larger classes were also more likely to report suspected abnormalities in elimination habits to the school nurse, suggesting that these teachers had gained more experience by the nature of the numbers of children they had encountered.

Children should normally void two to three times during the school day. Most children will void when given the opportunity, rather than waiting for their bladder to become full (Mattsson, Gladh, & Lindstrom, 2003). For those children who do suffer from voiding dysfunction, scheduled toileting for urinating and stooling throughout the day is essential for correction of the problem (Erickson, Austin, Cooper, & Boyt, 2003; Schulman, 2004). Alteration in normal bladder and sphincter function may occur if bathroom access is limited or voiding is not allowed when a child feels the urge to go and has not yet developed cortical inhibition of voiding (McKenna & Herndon, 2000).

There are many other potential causes associated with urinary incontinence in children. These include, but are not limited to, anatomic abnormalities such as ectopic ureters, vaginal voiding, and labial adhesions; tumor and trauma; behavioral problems such as attention deficit disorder; sexual abuse, stress, and toilet avoidance; neurogenic causes such as cerebral palsy and spinal cord abnormalities such as meningomyelocele, tethered cord, and tumors; endocrine problems such as chronic kidney disease and diabetes; functional disorders such as dysfunctional voiding, encopresis, and Hinman syndrome; and infectious processes such as foreign body, pinworms, vulvovaginitis, and urinary tract infections (Abidari & Shortliffe, 2002). Most of these causes may not be readily apparent to a parent or teacher, but deserve investigation and treatment by a qualified health-care provider.

IMPLICATIONS FOR SCHOOL NURSING PRACTICE

The involvement of the school nurse in the identification, assessment, and treatment of children with elimination problems is an essential component of the care of schoolchildren. School nurses can play a crucial role in helping teachers to understand normal and abnormal elimination patterns. The school nurse has the opportunity to assist teachers in early identification of those children who are having problems so that treatment can occur before teasing from peers begins and physical damage to the bladder and kidneys has occurred.

Without the benefit of formal instruction, it may take several years for a teacher to gain the needed skills to identify and respond appropriately to abnormal elimination patterns. A surprisingly small percentage of teachers reported ever having received information about normal elimination patterns or appropriate responses to abnormal patterns. Any child with abnormal elimination patterns deserves further evaluation for an underlying health problem as the root cause of his or her elimination dysfunction.

Optimal bathroom conditions include free access, and encouraged and scheduled bathroom breaks in a safe, accessible, and clean bathroom. These conditions are not present for most elementary school children. Improvement in bathroom facilities and accessibility should be an aim, particularly in view of the potential health consequences of continuing poor accessibility to dirty and unsafe bathrooms that currently exist in many schools. School nurses are appropriately qualified to bring these issues to the attention of teachers and school supervisors in their role of making the school environment conducive to the health and academic success of children.