BY THE AMERICAN ACADEMY OF PEDIATRICS NOV 2017
HOW TO POTTY TRAIN DIFFERENT TYPES OF SPECIAL NEEDS CHILDREN
The issue of when and how to begin toilet training can be particularly challenging for parents of children with special needs. While no parent wants to push an already challenged child to perform in ways that are impossible, the sense of accomplishment experienced when she does succeed in this important aspect of self-care can make an enormous difference in her level of self-esteem.
Perhaps more than other parents, those who have children with physical, intellectual, or developmental disabilities can appreciate the toilet-training process as a way to follow and celebrate a child’s overall growth. Rather than focusing on their child’s mistakes, which are inevitable in any case, they can use this opportunity to discover how he learns best and to demonstrate to him that he is able to progress.
Toilet training works best when parents of children with special needs have access to the guidance, instruction, and encouragement of their pediatrician, other trained professionals, or support groups. The first step you must take is to determine whether your child is ready to begin.
Signs of readiness are the same for your child as for all children:
- Is your child aware of the difference between being wet and being dry?
- Can she stay dry for at least two hours at a time?
- Can he sense when he needs to urinate or have a bowel movement?
- Is he capable of reaching the toilet or potty in time (perhaps with your help)?
- Can he undress and dress himself, or is she ready to learn?
- Is he motivated at some level to take this next step?
If you feel that your child is ready, ask your pediatrician for her opinion. She can examine your child to offer a physical assessment and perhaps offer special insight into the particular needs of your child. She can also provide further information that you may need before starting and let you know what types of special equipment may be advisable.
Children with special needs often begin toilet training later than other kids, frequently completing the process at age five or later. (Of course, children with severe physical disabilities may always need help with clothing and accessing the bathroom). Learning to use the toilet can be physically painful to some and initially incomprehensible to others.
A number of physical disabilities and illnesses can hinder a child’s ability to become fully toilet-trained or easily adjust to bathroom use. If your child faces such a situation, you will need to think about how her disability affects each stage of toilet training and how you can compensate for this disadvantage. Whether your child is unable to sense the need to urinate, has difficulty getting onto or staying on a standard potty or toilet, or must adjust or readjust to toilet use after having used an ostomy device, she will need extra support from you and her other caregivers as she learns to master this new skill.
Children with visual disabilities are unable to observe others using the toilet, so they cannot mimic the behavior. Without sight to help her, your child will need to rely more on language. You will probably want to wait until she is age four or older, (since language delays can accompany blindness)—so she can fully comprehend what you are telling her.
When you are ready, start bringing her with you to the bathroom. Allow her to locate the toilet. Place her hands on your shoulders so she can feel you sitting, explain what you are doing and why, and guide her hands to the toilet paper dispenser. Show her the flush handle and the sink for hand washing. Once you have placed a potty in the bathroom, lead her to it, and never change its location. Keep the path to the toliet obstacle-free.
A musical potty that is activated when urine hits the bowl will make the learning process more fun. Teach her to feel the inner edge of the seat before tossing in the toilet paper. A boy should also learn to sit and hold his penis down to avoid aiming issues.
Make a point of taking her to the bathroom at each public place you visit. Helping her familiarize herself with the wide variety of bathroom layouts and toilet types will build her confidence when away from home. Reward her progress with praise, hugs, or a small, favorite treat.
A child who is already fluent in sign language can rely on a combination of visual observation and explanations from you to understand what’s expected of her—much like any other child. Kids who do not understand your signals and simple signs may not be ready for toilet training until they are somewhat older.
Allow your child to observe you using the bathroom, and show her picture books about it. Choose one gesture or sign for the essential terms (pee, poop, potty, wet, dry, and need to go). Use these gestures each time you use the bathroom, and use them with her as well—signing “wet” (with a sad face) when you change her diaper or wet underwear, “dry” (with a happy expression) once she’s been changed, and “need to go” after lunch when it’s time to sit on the potty. As long as you are consistent and stick with the half-dozen signals you need, your child will get the hang of potty use without longer explanations. When she does, reward her with hugs, stars on a potty chart, or a treat.
Some conditions have no effect on a child’s ability to understand the process of toilet training but make it difficult for a child to comply. Your child may grow increasingly frustrated in her efforts to stay dry and may even give up trying. The best solution to this dilemma is to put your child on a regular potty schedule. By placing her on the potty frequently (reminding her every hour or so to visit the bathroom), you remove the burden of having to acknowledge so many times each day that she must interrupt an activity to tend to her physical needs. Going to the bathroom at the top of every hour can become a habit similar to brushing her teeth twice a day or receiving her insulin—freeing her up to focus on other activities between visits.
Cerebral Palsy (CP)
Children with CP tend to be slow in developing bladder control and may not have enough bladder awareness to begin toilet training at age two or three. She will need to be helped to develop an awareness that she needs to go and learn to delay urination until she is in position on the potty. She will need to remove her clothing, and hold herself on the potty (with supports) long enough to achieve success. Again, these challenges mean that it is usually best to wait until she is older.
Chances are that limited physical activity, undeveloped muscle tone, or medications tend to cause constipation for your child with cerebral palsy, so pay special attention to her diet as you initiate the training process. Be sure that she is drinking plenty of fluids and ingesting lots of fiber.
As she begins to practice removing her clothes before getting onto the potty, make it easier by providing clothes with Velcro fasteners or loose elastic waistbands. (She may find it easier to remove her clothes while lying down.) Since she will have trouble supporting her back, you will need to provide a special potty with back and side supports. (Potties designed to fit in a corner work especially well, since the right-angle back support holds the child in position with shoulders forward, hips bent, and knees parted.) If your child has severe disabilities, you might begin by sitting in a chair with the pot from a potty wedged between your knees. Place your child on the potty with her back against you and hold her in position until she urinates or has a bowel movement. Later, you may be able to graduate to a potty with adequate supports.
Spina bifida, spinal cord injury, or spinal tumors create toilet-training problems for young children similar to those of cerebral palsy, but since most children with this condition never develop an awareness of when they need to go, few can ever fully use a toilet. You can, however, teach your child to remove urine through a catheter on a regular basis, and to visit the bathroom for bowel movements on a regular schedule. (A high-fiber diet with plenty of liquids and meals served on a regular schedule will make this process easier. Sometimes a stool softener or even a suppository or enema is required.) Since your child will find it difficult to remove her clothing, be sure to provide her with Velcro fastened clothes and allow her to lie down to undress if necessary.
Parents of children with physical disabilities such as cerebral palsy or spina bifida may become so distracted by the need for special equipment or physical support that they neglect the necessary cognitive and emotional input that all children need to succeed at toilet training. Don’t forget, while installing that special potty in the bathroom, to talk to your child about bathroom use and why it’s important, to let her observe you and others using the bathroom, and to praise and reward her when she succeeds even a little bit. Remain firm about the schedule or routine you have created—unless the experience becomes negative.
Behavioral Disorders (BD)
Your experience toilet-training a toddler with BD will depend a great deal on your child’s temperament, behavior patterns, and coexisting conditions. Toilet training can be particularly trying for parents of kids who have BD—including those with autism, fetal alcohol syndrome, oppositional defiant disorder, and, in cases when it is diagnosed this early, attention deficit /hyperactivity disorder. Often these kids are unmotivated, or insufficiently equipped, to respond to the social reinforcements that work so well with other kids, though small tangible rewards such as candy or a toy can be effective. Most find it extremely difficult to adjust to any change in routine. Some with sensory input issues can become upset by the frequent arranging of their clothing, touch by the adult, and the unfamiliar surroundings of the bathroom.
Kids with BD do not naturally imitate their parents’ or peers’ behavior, while others learn only through simple imitation or other concrete, nonverbal demonstrations. Such complications in the training process mean that early efforts can create a high level of frustration. Still, nearly all kids with BD can be toilet-trained—though in some cases the process may take up to a year or more.
Observe your child and consider her personality traits. If she dislikes entering the bathroom, find out why—the smell of disinfectant? the cold floor? the flushing toilet?—and change or neutralize it if possible (change cleaners, put on socks, keep house quiet).
What foods, toys, or other objects is she most passionate about? (These can be used as tangible potty-training rewards.) How does she learn best—with firm but gentle physical demonstrations (being placed on the potty at regular times), a formal routine containing a series of simple and predictable steps (verbally explained and reexplained, illustrated with pictures, or listed on a chart), or offhand comments and conversations that inform without inviting resistance?
Most kids with with a intellectual challenges can be toilet-trained. It will be easier if your child achieves some verbal ability, is able to manage her clothes, and shows awareness of the need to go. During toilet introduction, keep your explanations simple. Start by checking the state of her diaper/underwear every hour and offering a comment, “Wet!” or “Dry!” If wet, shake your head and then, after you change her, smile and say, “Dry!”
Bring her with you to the toilet when you need to use it. Smile and say, “Dry!” after you’ve finished and pulled your pants up. If at all possible, have your child observe other children using the bathroom, too. He may make the connection between himself and another child more easily than between himself and you. If she has a favorite doll, use it to play “potty” as a demonstration.
Begin setting her on the potty at frequent regular times and then gradually settling down to the times when she usually voids. Keep her on the potty for up to ten minutes at a time (try reading to her while she sits). Once she urinates, give her a smile and say, “Pee!” Help her wipe off, and then praise her with a happy, “Dry!” and give her a treat. Training will work best by focusing on elimination first and addressing other skills later. #
Courtesy of the American Academy of Pediatrics, aap.org.