Toilet Training a Child with Special Needs
Claire Keeler is a pediatric nurse practitioner who was a fellow at the University of Cincinnati University Affiliated Program. She conducted a study on toilet training children with special needs.
Parents often find that toilet training their child can be a frustrating process. Some children may toilet train quickly and easily, but for many children it can take time. If a child has special needs, it can be even more difficult. Parents know that every child is unique and different. Advice from other family members or friends may or may not be helpful. Typically, children can achieve toilet training by 2 to 3 years of age, regardless of special needs. Toilet training increases a child’s self-esteem and independence, especially as he or she enters school or daycare. It can also be a stressful situation. However, only you and your child can determine whether they are ready to learn.
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Article Sections: Is your child ready to begin? / Readiness Checklist / Environmental Factors / Your child is ready – now what? / Tools for Toilet Training / Overcoming Difficulties / Communication / Related Resources
Is your child ready to begin?
There are several steps to follow to help clear the way:
- Have your child seen by your pediatrician for a medial check-up to make sure he or she is healthy before you determine readiness to potty train. Continence can depend on whether or not your child has a disease or disorder that affects the bowel or bladder.
- Also, be sure and let your nurse practitioner or doctor know if your child complains of pain when urinating, the urine has blood or pus in it, the urine smells foul or different, your child is always dribbling urine, or has a really hard time starting to urinate. These problems need to be addressed before toilet training begins or at any time in the process.
- Additionally, pain on urination or defecation can hinder the readiness process. The skin covered by a diaper can become red and irritated. This may cause pain when your child urinates, and may cause him or her to withhold urine. It is important to always keep the diaper area clean and dry so your child will not want to hold the urine.
- Often, children feel inhibited about having a bowel movement outside of a diaper. If they are pressured to have bowel movements only in the toilet before they are ready, they may stop having bowel movements altogether. Likewise, if it hurts to have a bowel movement because of hard stools, your child is not going to want to pass it. This can lead to a vicious cycle. Slightly changing your child’s diet may help, but check with your child’s physician first. Fruits like pears, prunes, and peaches, which are high in fiber, can soften stools. Parents know which foods will work for their child.
Sometimes, medication is necessary for constipation to keep stools soft. Laxatives most commonly used are stool softeners like docusate sodium, osmotic laxatives like lactulose, and stimulants like Senokot syrup. Other children may respond to suppositories or enemas. Again, it is important to always check with your nurse practitioner or pediatrician to see what medicine (if any) is appropriate.
The Readiness Checklist can help you determine if your child is ready to begin the toilet training process.
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Readiness Checklist
Your child’s readiness to toilet train is related to his or her level of growth and development. The following items are organized according to motor, cognitive, and language development as well as toileting skills. Some of the items in the list may not apply to your child. The more items that do apply, the more likely your child is to begin toilet training.
MOTOR
- My child can sit with or without support
- My child attempts to squat without losing his/her balance
- My child is walking without help
- My child is able to help dress and undress his/her self.
COGNITIVE
- My child searches for his/her toy
- My child imitates me and/or others
- My child plays make-believe
- My child is able to sit down and play quietly for for about five minutes
LANGUAGE
- My child understands simple requests like, “Where is Mommy?”
- My child is able to show his/her needs using words, signs, or gestures.
- My child has a name for urine and bowel movements
- My child tells me when his/her pants are wet or soiled
TOILETING
- My child is able to stay dry for at least an hour
- My child is aware of what a potty or toilet is for
- My child is aware of being wet or soiled
- My child’s bowel movements are solid and well-formed
- My child is not currently experiencing a stressful situation like birth of a new sibling or changes in childcare arrangements.
Environmental factors
Begin training when your child is starting to learn cooperation, and when there is not a lot of stress at home. For instance, do not start toilet training around the holidays, when weaning him or her from a bottle, or soon after bringing home a new brother or sister. Also, from a practical point of view, it may be easier to start potty training when it is warm outside because your child will be wearing less clothing.
One of the first steps of toilet training includes keeping a diary for about three to five days. The diary should note when your child goes (either bowel movement or urine), when she or he is soiled, and what and when your child drinks. This will show you your child’s toileting pattern and help clue you in as to when to have him or her start sitting on the potty.
Even if your child is fully trained, accidents often happen. Accidents may occur when your child is excited, fearful, absorbed in play, or awakened from a bad dream. They may also occur if there is any change in home routines, like the birth of a sibling, a move, or starting school. When your child is sick, expect accidents until he or she is better. However, if there are repeated, unexplained accidents, there is the possibility of an allergic reaction or an illness. In this case, you need to contact your nurse practitioner or doctor.
Your child is ready – now what?
After you and your child have determined that it is time to potty train, take him or her to the store and buy a potty. After choosing and buying the potty chair, (See Rifton’s Toileting System) start having him or her sit on the potty, clothes on, while you sit on the toilet. You can give your child a snack or read aloud to keep him or her sitting on the potty in order to establish a daily routine.
Then, during the next week or so, ask your child if it is all right to take his or her diaper off while on the potty. In the next couple of weeks, take your child to the potty after a bowel movement and place it in the potty. This lets him or her know that this is where the bowel movement belongs. Do not flush it in front of your child (for some children, it may be fun to watch it flushed, but others may be frightened and confused about where it went.) Flush the bowel movement when your child loses interest and leaves the room.
If you meet with resistance to any of these steps, just back up and forget training for a couple of days.
The next step is to offer to remind your child to go to the potty every hour. When he or she goes, leave it there and offer congratulations. Nighttime training should begin only when your child is dry during naps or dry for at least six hours.
Whatever system you decide to use, reward your child’s successes with a lot of praise. It is important to be encouraging and positive. Occasionally, there will be accidents. The important thing is how you handle them. It is okay to show mild disappointment, but never scold, punish, or make a really big deal out of it. Tell your child it is okay and he or she will go in the potty next time.
Tools for toilet training
There are many helpful techniques that may aid parents in the training process:
“Role modeling” may allow your child to learn by imitation.
- Try an “open-door policy” in the bathroom so your child may see other family members using the toilet.
- Try placing a nonabsorbent cloth in your child’s diaper so he or she can be aware of feeling wet.
- Small rewards may be given to encourage the child to sit on the potty longer or after they have successfully used the toilet. For instance, one parent put a basket on the top of the refrigerator full of inexpensive trinkets she had wrapped like tiny presents. Each time the child used the toilet she would give him a prize. You can help make the toilet-training process fun for both you and your child.
- There are many products available that can help with toilet training. There are also musical potties and potty charts with fun and colorful stickers. Another idea is to put a couple of drops of food coloring in the toilet bowl and have your child guess what the color of the water will change to after he or she urinates. Buy underwear with your child’s favorite cartoon character. Make it a game where your child tries to keep the character from getting wet. Daytime wetting alarms (a sensor in the child’s pants that signals when wet) may help the child notice when he or she is wet.
Overcoming difficulties
The type of difficulty your child has with toilet training (bowel training, bladder training, or both) and the potential to achieve control depends on your child’s special need and whether it is a physical or cognitive difficulty and the degree to which your child is affected. For some children, it may be difficult to reach the toilet and actually sit on it. Parents may have to help with positioning and keep their child in position while on the toilet. Other children have difficulties with communicating that they need to go, or parents have difficulty with communicating the ideas associated with toilet training.
There are some adaptations to the toilet area to help your child with a physical disability sit on the toilet. (See Rifton’s Toileting System) For older or taller children, there are raised seats along with safety rails to aid the child with positioning on the toilet. For toddlers, several brands of potty chairs have backs that can support a child leaning back. Positioning your child differently on the toilet seat may also help. Some experts have suggested that children straddle the toilet seat or potty chair. Seating the child sideways on the toilet may also be helpful.
Communication
When communication is the problem, it may be easier on you to show your child where the bowel movement goes (in the potty) and allow him or her to watch you and other family members using the toilet. It may be necessary for children who have communication problems to work directly with a healthcare professional, such as a nurse or therapist, to help you with setting and achieving these goals.
Exceptional Parent Magazine October 2000
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This article reprinted with the expressed consent and approval of Exceptional Parent, a monthly magazine for parents and families of children with disabilities and special health care needs. Subscription cost is $39.95 per year for 12 issues; Call (877) 372-7368.
Related Resources:
Teaching a Basic Function:
On-line article exploring several techniques to use when toilet training children with cerebral palsy, by Ginny Paleg, PT
Steps to Independence Book by Bruce L Baker and Alan J Brightman
Potty Learning for Children Who Experience Delays (video)
SR Hays, MS, RN, CRRN
Running Time: 65 minutes
Susanne Hays outlines ways to help children with disabilities manage their toileting needs independently. The video portrays the situations of three individual children. Hays and the parents describe the potty training goals and successful strategies, including use of a time-voiding schedule and a reward/reinforcement system.
Toilet Training Without Tears Book by Dr. Charles E. Schaefer.
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