Becoming toilet trained is a milestone all parents strive for, and for some parents of children with additional needs, this milestone can seem unobtainable. However, experience has taught us that for many children with additional needs becoming toilet trained is an achievable goal. June Rogers MBE shares her expertise on where to start.
All children are different and there is very wide variation in the age at which children are fully toilet trained. The time it takes and the overall success with toilet training will depend very much on your child and your approach. Some children will always require additional help or support to use the toilet or need the occasional prompt, particularly if they are busy or distracted.
Most children without additional needs become clean and dry in the day between the ages of 2 and 4, however, there is good evidence that children are now getting toilet trained later. In the 1960’s there was a trend towards a very ‘child-centred’ approach when the family would hold off toilet training until the child showed an interest or appeared ready. That approach worked very well at a time when children wore cloth terry nappies. The parent was able to identify quite early on when the child was developing bladder maturity with increasing time between going to the toilet and being dry after naps. Also the child had the opportunity to learn to recognise the consequence of full bladder signals by feeling very wet. These factors were often the ‘triggers’ that led to starting toilet training.
Unfortunately, that ‘wait until the child is ready’ approach still persists today despite the fact that most children are in disposable nappies. This means that many of the factors that would trigger the family to start toilet training are no longer evident and when parents are asked why they have not started to toilet train their rising 3 year they say it is because they do not think he or she is ready – and from a child’s point of view why would you want to stop wearing your nice comfortable ‘portable toilet’ that is so convenient to use!
When to train
A number of children without additional needs, may now start nursery or pre-school in nappies or pull-ups, however after a few weeks they suss out that they need to be using the toilet like everyone else and very quickly become fully toilet trained. For children with additional needs and especially learning difficulties this may not happen and this often results in toilet training being delayed until the child ‘appears ready’. Unfortunately for some children, if we waited until they appeared ready and interested in toilet training we would be waiting a very long time!
Experience has shown us that we need to take a more structured approach to toilet training children with additional needs, particularly if it affects their understanding and social awareness, than we do with other children. Becoming toilet trained is the interaction of two main processes – maturation of the bladder and bowel and understanding and social awareness. For children with such additional needs it is often their lack of understanding and social awareness that results in delayed toilet training rather than an inherent problem within the bladder or bowel. Toilet training should, therefore, start as soon as the bladder matures and not wait until your child appears ‘ready’.
Signs to look for include:
- Being able to stay dry for increasing periods of time.
- Regular bowel movements.
- Able to indicate their needs (using signs, words or gestures).
One step at a time
Toilet training is a skill that can be broken down into a number of steps. By addressing each step one at a time it makes the whole process a lot easier and more manageable for the family. Putting your child on a toilet skill development programme enables him or her to learn the skills they would need in order to be toilet trained and once those skills are in place more formal toilet training, involving removing the daytime nappy and scheduled sitting on the potty or toilet, can begin.
‘One step at a time’ is an approach that has been used successfully with children with a whole range of additional needs including learning difficulties. Each step brings your child closer to the goal of being toilet trained. It is suggested this programme is commenced in the child’s 2nd year.
Step 1: setting the scene
This step is mainly about your child learning new skills and starting on the path towards toilet training. It involves getting into a different regime for nappy changing including only ever changing them in the bathroom. This enables them to be more aware of the connection between wees and poos and the toilet. *If your child is able to stand unsupported we also suggest he or she is changed standing up as that way they can get more involved with the process. Learning about wet and dry is also introduced at this stage and can include putting cotton pants on your child before their nappy, placing a piece of folded kitchen towel, that doesn’t disintegrate, into their nappy or playing water games so they can understand the meaning of wet.
Step 2: developing the skills needed
This step introduces sitting on the toilet or potty, learning to pull pants up and down and knowing what the toilet is for including flushing and washing and drying hands.
Step 3: raising awareness
This step involves identifying your child’s habits – such as how long he or she can stay dry for and if there is a regular time when they have opened their bowels. By this stage your child should be able to stay dry for increasing periods. Before he or she can move on to the next step we would suggest they need to be able to stay dry for at least 2 hours if not longer and have no underlying problem with their bowels such as constipation.
Step 4: using the toilet
This is the stage when we expect wees and poos to start happening in the toilet. The necessary skills will have been practised so at this stage we would expect your child to cooperate when taken to the toilet and happily sit on and attempt to pull their pants up and down. At this stage begin moving your child out of disposable products into ordinary, washable underwear or trainer pants. The skills introduced and developed at this stage include using the toilet to wee and poo, bottom wiping and using unfamiliar toilets.
Time to get going
The time it takes and the overall success with toilet training will depend very much on your child’s individual ability and will vary from child to child. Some children will always require additional help or support to use the toilet or need the occasional prompt, particularly if they are busy or distracted.
Once the toilet training starts it is important that everyone involved with your child, both at home, nursery, childminder or school, is aware of the programme so they can follow it too and a consistent approach can be maintained.
It is important to stress that all children, including those with additional needs, who have any continence or toileting problem should have a holistic continence assessment looking at everything involved in the process, to not only identify and treat, if necessary, any underlying problem but also to help inform the direction of the toilet training programme to be implemented.
For further information about the above programme contact Bladder and Bowel UK. June Rogers MBE is Paediatric Continence Advisor to Bladder and Bowel UK.
Local children’s continence services
Children’s continence services should offer advice and support for all bladder, bowel and toileting problems as well as provision of products and equipment as appropriate. Currently there is no standard format for these services so availability will differ from area to area. The majority of continence services for children sit within or run alongside the adult continence service, in some areas the service sits within the children’s services directorate. Many areas may only have services for children with specific issues, such as bedwetting, which are usually run separately by school nurses. Contact your health visitor or school nurse to see what services are available in your area.
Bladder and Bowel UK (formerly PromoCon)
Bladder and Bowel UK provides impartial information and professional advice to both healthcare professionals and the general public in relation to children and adults with bowel and/or bladder problems. It is recognised as the leading national/international source of information regarding continence products, equipment and services. It also provides high quality study days, tailor-made training and an annual Continence Symposium. A range of free downloadable resources are available from the website.
Helpline: 0161 607 8219
ERIC is the UK’s only childhood continence charity. It works to reduce the suffering to children and young people caused by bedwetting, daytime wetting, soiling and associated conditions and their prevalence. Its website has a lot of useful information on potty training as well as products.
Helpline: 0845 370 8008
New guidance for the provision of continence containment products to children and young people, introduced in 2016, is available to read here
This article was previously published in My Child and Me magazine.