A common concern that most families with children have had ‘not being able to indicate toilet needs!’ When children soil their pants or when there is an “accident”, especially when out at social gatherings parents feel helpless, uncomfortable, embarrassed and even guilt-ridden.
The age at which toilet control is learned varies based on geographical location, ethnicity, and family background. It is an acquired skill to indicate the need for urination or bowel movement. Families in general start training young children anywhere between six months to three years of age.
In children with developmental delays and disabilities indication for toilet, needs is often absent and or is difficult to train due to:
a) delayed language acquisition
b) lack of language/ gesture comprehension
c) limited attention span to wait
d) lower cognitive skills as compared to typically developing peers
e) inability to identify bowel movements
f) a need to pass stools only on a diaper (routine pattern)
g) difficulties in transitioning to toilet seats (as it can be threatening for our children)
Considering the challenges, it becomes crucial for families to work along with their therapists to achieve quick success.
Top Three Pre-requisite Skills for Toilet Training
Firstly, to start with, we must train our children to be able to sit independently and work along with the parent on a given task at least for about 15 minutes. You may include activities such as painting, cutting & pasting, board games, reading, or even writing to reach this target.
Secondly, get your little one to follow simple one-step instructions. For example: stand up, sit down, wait, let us go together, look at me, give me a high five, squat etc. You will identify that these are some instructions you may have to give during a toilet training session.
Thirdly, your child must have joint attention as you are on a training task for which the parent, as well as the child, need to focus on one goal. You may start with a simple social game such as tickling, or playing peek a boo, and gradually transition to reading a story together. This is useful when they sit on the potty chair and wait for bowel movements.
Lastly, introduce vocabulary relevant to toilet training. See the list in the annexure attached.
More Practical Tips to Get Started.
Sussu (synonym used for urination in India) Training
Take your child every 30 – 45 minutes to urinate on the toilet or potty seat as per weather conditions. While walking back and forth use statements like: “I do sussu in the washroom”, “sussu time”, and “let’s go for sussu” depending on the child’s language comprehension. You may customize it based on the child’s vocabulary. Gradually prolong the gap between each time they visit the toilet to facilitate bladder control gradually and steadily. If your child gets familiar with the routine, he is sure to follow an instruction associated with “sussu time” independently. Eventually, you may extend the time to an hour while the child is also acquiring toilet control and is getting habituated to urinating only in the washroom.
In case of an accident outside the washroom have your child clean it with minimal to no assistance depending on their level of independence. You may accompany the process by stating “oops that was an accident”, “nay, it's smelly smelly”, “dirty dirty” etc. Statements must be varied with the child’s understanding. Children soon figure out it's easier to use the washroom than to clean the mess.
Look for signs that indicate a need to urinate (may be a puzzled look on your child’s face or s/he walks to a corner) and facilitate with positive gestures and words by taking your child to the washroom and communicating simultaneously as motioned above. Appreciate your little one for the sign, remember that behaviours that are appreciated often get repeated!
Show your child videos and books on sussu training to help them comprehend the process and be able to imitate. Caution: Excessive screen time is unhealthy for children.
Provide structure by familiarizing the place and time and remaining consistent. It takes about 3 days or more for our bodies to get acclimated to a certain routine or adapt to a new change. Allow your child the time they require and be patient.
Begin with having your child drink warm water or milk depending upon your home routine.
Find a suitable place closer to the toilet as it helps transition to the toilet seat faster. However, if your child is big enough to use a toilet seat you may directly work with having your child sit on the toilet seat with the support of a stool to rest their feet
For children using the toilet whose legs aren’t reaching the ground, ensure to provide support by placing a stool or small bench. Such seating is much needed for postural control and for children with gravitational insecurity.
Ensure your potty-training sessions do not prolong beyond 20 minutes as children may forget why they are there for.
Allow your child to perceive bowel movements by providing a calm environment without distractions and alerting noises at least until they learn the process.
In newborns, voiding is a reflexive pattern which gets mature for a typical 2-year child. He /she may urinate when placed on the toilet and gets feedback through bowel movements when placed on the toilet. A typical 3-year-old child indicates the need for toileting most of the time with rare toilet accidents. The child may learn to use the toilet independently provided with adult help for cleaning themself.
A child with atypical development faces more challenges to reach independence than other skills.
Children with severe attention deficit hyperactivity disorder may not be aware of the sensation of voiding due to restless behaviour or poor sensory registration. These children may prioritize for moving around or engaging in physical play than focusing on the feedback from the bowel and bladder.
Children with low scores on cognitive skills may require repeated training.
Increasing fluid intake and adding fibre rich diet to those children will improve the frequency of toileting also. Picky eaters or children who prefer junk or processed food are prone to constipation.
Children with poor visual skills, communication skills or cognitive skills have difficulty locating the toilet. In such cases, Occupational therapists, Speech therapist and Special educators help facilitate the foundation skills. They require communication skills to express themselves verbally or using gestures.
Physical impairment (children with cerebral palsy or muscle weakness may have difficulty sitting on the toilet seat due to muscular impairment)
Children with hypersensitivity to touch may avoid using the wet toilet or avoid entering a toilet, eg: Avoid entering the wet floor, show resistance to sitting on the toilet seat, prefers standing instead of sitting and voiding, may resist using the public toilet etc.
Where do we start?
Visual scheduling– to prepare a to-do list of the procedure for using the toilet. [like, go to the toilet, remove pants, pass bowel, wash, pull pants up, wash self or request help (as per developmental skills)
Show videos or pictures of squatting so the child understands the position while voiding
Using simple words, signs, and picture cards during each trip before toileting will be helpful for the children who do not follow the sequence. If the child was engaged in particular activities direct them to continue with the same activity after toileting.
Achieve Generalization once the child is independent in your own home and follow it up by using different bathrooms in different places.
Modify the toilet environment (keep the floor dry if the child is hypersensitive to touch and adjust the illumination to dim if the child is hypersensitive to light)
Avoid punishing the child for any accidents, instead offer support and reassurance.