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Toilet Training

Many children with severe cognitive and/or physical disability can be toilet trained. The method of toilet training is not a slowed down version of that used for a typically developing toddler. More specific behavioral models are used and generally fall into one of two major categories, scheduled or timed seating.

Scheduled

The child's natural patterns are monitored for several weeks. Subsequently, the teacher or parent takes the child to the toilet on a pattern to match his/her natural rhythms. If the child does not urinate or defecate at that time, toileting is repeated every 15 minutes till the child either goes in the toilet or the diaper. Subsequently, the next time for toilet setting is the next "high probablity" time. Positive reinforcement is given for any output into the toilet and also dry diapers.

Timed Seating

Toileting becomes the primary goal for the child within the school setting for a period of several weeks. A behavior program is structured where the child is encouraged to drink fluids (in some cases extra fluid is given via the child's feeding tube) and, initially, the child moves through 30 minute cycles with 5 minutes of encouraged fluid intake, 15 minutes of toilet sitting, and 10 minutes of dry pants checks (twice during the ten minutes) while wearing regular underwear. Positive reinforcement is given for product in the toilet and for dry pants. Accidents are managed with neutral affect.

Role of the Medical Home

Determine if the family considers toilet training a goal. It is important to touch on this issue early (age 2-3) indicating to the family that, while achieving continence might be later, it is likely something their child can achieve. Also find out when parents desire to focus on this goal.
Basic requirements to determine when the child is ready include:
  • at least 30 minute dry periods when in diapers;
  • shows recognition of wetting/soiling (not necessarily discomfort, sometimes child has to be changed into regular underwear instead of absorbent diapers/pull-ups for a few days to assess this);
  • age generally over 4 and a half years;
  • displays no fears of being in, on, or around the bathroom (if fears exist, a behavioral desensitization program needs to be done first); and
  • all medical or physical barriers (e.g.constipation) have been ruled out.
Being able to communicate the need to be taken to the bathroom and the functional ability to independently toilet are NOT required for toilet training.

Toilet Training as a School Goal

Toilet training often begins as a school goal and, once successful, transitions to the home environment. The family will need to work with the teacher and the IEP team to determine when toilet training best fits into the child''s educational program. If the teacher or school indicates that they have had limited experience, the family should request that a special educator within the district be identified to assist. Prior to beginning, the needed consultants (PT, OT, ST) should be involved to address assistive equipment and communication programming needed to accompany the toilet training program. These consultations can be obtained through the school services but, on occasion, private consultation may have to be arranged if the school lacks adequate resources.

Transition Toilet Training to the Home Environment

Once the child is successful at school, or in the rare case that initial training begins in the home, the physician will need to arrange for consultation with a private PT and OT for equipment in the home environment. The primary care physician should monitor this goal at well-child-exams to determine the level of progress, identify possible problems impeding progress (e.g. neurogenic bladder, constipation), and support the family transitioning to the home environment.
Once continence is achieved, the clinician must continue to monitor this issue, arranging PT/OT consultation for additional or updated equipment or training to enhance independence as the child matures, and/or to teach parents optimal transfer techniques. Note: Regressions are common and evaluation by the clinician may be helpful.

For Specific Diagnostic Groups

Although there has been little study, the following information about specific diagnostic groups may be helpful in providing guidance to parents.
Children with Cognitive Impairments - In one population-based epidemiological review, 63% of individuals were continent by age seven and 83% by age twenty. Not all of the individuals in the study had the benefit of appropriate training programs.
Children with Autism - In retrospective surveys, parents indicated that they would wait till at least 4-5 years of age to start and that it took, on average, 1.6 years to attain urinary continence and 2.1 years for bowel continence. 95% were successfully trained, with 75% achieving the ability to self-initiate toileting. Common issues for parents included frequent regressions (often due to routine changes), constipation, night incontinence, and behavioral concerns (bathroom aversions, sensory issues, playing with the toilet or product etc.).
Children with Cerebral Palsy - One teacher did a retrospective review of children with CP who attended a developmental preschool. Only 2 of 27 children did not achieve continence within 5 weeks of training at the preschool. The preschool attributed their success to higher expectations (many parents had not attempted to train their child), routine, having peers available with similar goals, and having more appropriate equipment through PT/OT consultation.

Resources

Information & Support

For Professionals

Toilet training information (Rifton manufacturers)
Information about all aspects of toilet training of children with special health care needs, including information about potty chairs.

For Parents and Patients

Toilet training information (Children with special health care needs)
Information from About.com, including links to other sites

Helpful Articles

Azrin NH, Sneed TJ, Foxx RM.
Dry bed: a rapid method of eliminating bedwetting (enuresis) of the retarded.
Behav Res Ther. 1973;11(4):427-34. PubMed abstract
A very dated publication, but the most replicated timed sitting program (with negative reinforcement removed!)

Boswell, Susan and Gray, Debbie.
TEACCH - Applying Structured Teaching Principles to Toilet Training.
University of North Carolina at Chapel Hill; (2005) http://www.teacch.com/toilet.html. Accessed on 02/22/05.
An article specific to issues for children with autism, from the Treatment and Education of Autistic and related Communication handicapped CHildren Division at the University of North Carolina at Chapel Hill.

Richmond G.
Shaping bladder and bowel continence in developmentally retarded preschool children.
J Autism Dev Disord. 1983;13(2):197-204. PubMed abstract
A good example of a modified timed sitting program in action.

Moreno, Kent.
Toilet Training Made Semi-Easy.
the Down Syndrome: Health Issues site; (1996) http://www.ds-health.com/train.htm. Accessed on 02/22/05.
Offers toilet training suggestions specific for children with Down syndrome.

Axelrod, Craig.
Toilet Training Children with Deafblindness: Issues and Strategies.
Texas School for the Blind and Visually Impaired; (1992) http://www.tsbvi.edu/Outreach/seehear/summer00/toilet.htm. Accessed on 02/22/05.
Provides advice specific to children with multiple sensory impairment.

Smith L, Smith P, Lee SK.
Behavioural treatment of urinary incontinence and encopresis in children with learning disabilities: transfer of stimulus control.
Dev Med Child Neurol. 2000;42(4):276-9. PubMed abstract
Gives some very nice examples of how to work with the child who has become conditioned to the diaper and has difficulty transferring the stimulus to void to the toilet.

Wheeler M.
Toilet Training for Individuals with Autism and Related Disorders.
Arlington, TX: Future Horizons, Inc.; 1998. 1885477457 http://store.fhautism.com/p-157-toilet-training-for-individuals-with-a...
An excellent paperback for parents of children with autism approaching this goal.

Authors

Author: Lisa Samson-Fang MD, 10/2008
Content Last Updated: 6/2011