Children with continence problems may experience social and psychological problems. A toolkit aims to support schools to provide appropriate care during the school day
The charity organisations Education and Resources for Improving Childhood Continence and PromoCon regularly receive feedback from health professionals, children and families suggesting that schools struggle to cope with childhood continence problems. This article outlines the responsibilities of schools to understand continence problems, implement effective policies and procedures to meet children’s needs, and recognise those children’s rights to be supported in achieving continence and independence. It also describes the development of a toolkit called The Right to Go.
Citation: Rogers J, Perez J (2014) Helping schools to manage continence problems. Nursing Times; 110: 18, 20-22.
Authors: June Rogers is team director at PromoCon; Jenny Perez is chief executive of Education and Resources for Improving Childhood Continence (ERIC).
- This article has been double-blind peer reviewed
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Continence problems in childhood are common and, based on our experience, primary and secondary schools may have at least one child with a wetting or soiling problem on their roll. The current trend for later toilet training means a number of children will start pre-school nursery classes still in nappies.
Approximately 900,000 children and young people in the UK aged 5-19 years, out of a population of 8.5 million, have a continence problem (National Institute for Health and Care Excellence, 2010a). At the age of 4.5 years, 15.5% of children have daytime wetting and 9% have daytime faecal incontinence (NICE, 2010a). In England, around 14,500 children are admitted to hospital every year with problems such as chronic constipation and urinary tract infections (UTIs). We know that 80% of these admissions could be avoided through improved care and support in primary care (NICE, 2010a).
An increasing number of children and young people who have continence problems associated with long-term conditions and complex care needs are attending mainstream school. Although some of these pupils have short-term needs, such as being helped to complete a toileting programme, many require continuous and ongoing care and intervention while at school, including intimate or invasive healthcare procedures. It is important that appropriate policies and guidelines are in place to care for these children and the need for individualised healthcare plans is recognised.
Continence problems can have a significant emotional impact and increase the risk of bullying and behavioural problems in children and young people. Childhood bladder and bowel conditions that are poorly managed can have a profound effect on children’s physical, emotional and psychological health and wellbeing, as well as a negative impact on their learning (Joinson et al, 2007).
Managing problems can be stressful for parents and carers, and can strain family relationships. Although most parents do not get angry with their child as a result of wetting or soiling problems, there is evidence of a link between that and punishment, including physical abuse (Butler et al, 2005). Children with continence problems should always be dealt with sympathetically and in a non-punitive way.
It is vital that school staff members understand that wetting and soiling problems are usually linked to an underlying bladder and/or bowel problem and “accidents” happen outside the child’s control. Continence problems in children and young people may take many months or years to resolve so it is important that they are diagnosed and managed early. If conditions are not managed appropriately and become chronic, they may result in the need for referral, treatment and/or surgery in secondary care.
Under the new Children and Families Bill 2013 schools are legally required to provide appropriate support for children with medical conditions. This addition to the Bill was lobbied for by the Schools Alliance, a coalition of charities representing children with a wide range of long-term medical conditions.
The supporting guidance for schools (which is currently at draft stage) will highlight the role of school nurses in making sure that educational establishments meet their responsibilities, for example, by helping them to identify training needs. School nurses will also play a key role in helping to ensure that children who have medical conditions, such as bladder and bowel problems, also have an individual healthcare plan in place.
Identifying the extent of the problem
In 2012 a survey was carried out by the Association of Teachers and Lecturers (ATL) and Education and Resources for Improving Childhood Continence (ERIC) to help identify the scale of the problem (ATL, 2012).
In total, 848 school staff working in state, independent and academy primary schools in the UK during October and November 2011 responded to the
members. The respondents included teachers, teaching assistants and special educational needs staff, who were surveyed using a questionnaire. Of the respondents, 62% reported there being an increase in the number of children who had wetting or soiling problems during the school day over the previous five years. One teacher reported that nearly half of the children starting nursery were not toilet trained.
In total, 90% of survey respondents reported that the classroom assistant had the responsibility for dealing with a child who has a toileting accident; however, 80% of respondents said their job descriptions did not specify that they should deal with childhood continence problems. It is vital that school staff are supported by appropriate policies and procedures that highlight their responsibilities and outline the training they need if they are to be able to effectively support children who have continence problems.
In 2013 ERIC carried out an online survey of 105 children with continence problems via its website. The results highlighted that more than two-thirds of respondents (69%) did not feel able to talk to school staff about their problem (ERIC, 2013). There is clearly confusion and a lack of clarity about who is responsible for helping these children and where they obtain support.
Developing the resources
PromoCon staff who have backgrounds in paediatric continence promotion and experience of working with schools set out to develop a resource for schools. This involved a literature search to identify relevant education policies and guidelines that would support best practice. Up-to-date information, including relevant
NICE guidance on the management of children with wetting and soiling problems (NICE 2010b; 2010c; 2007) was also identified and reviewed.
It was clear there were gaps in the information and resources available for school staff so an information toolkit - The Right to Go - was developed to support schools, health professionals and parents, in a practical way, when working through the issues around toileting problems at school. The contents are outlined in Box 1. The toolkit is available as a 20-page document as well as a shorter 8-page leaflet.
Box 1. Information in The Right To Go toolkit
- The development of common childhood continence problems
- How to create a continence policy
- How to create individual healthcare plans
- How to promote bladder and bowel health in schools
- Ways to support children with special needs who have continence issues
Available at: eric.org.uk/right-to-go
We involved clinicians, voluntary- sector organisations and the education sector in developing the toolkit. A multidisciplinary and stakeholder group that included parents, health professionals and teachers reviewed and commented on each draft of the materials. We hoped that involving stakeholders from across health and education settings would increase the chances of the toolkit being implemented.
How the toolkit helps
The toolkit resources provide schools with a comprehensive guide about the management and support of pupils with wetting and soiling problems. This includes setting out the legal responsibilities in relation to continence management within early years and school settings.
Schools must recognise their obligation to meet the needs of children with delayed personal development in the same way as other difficulties such as delayed language. It is also important that children are not excluded from normal school activities solely because of continence problems they may be experiencing.
In addition, asking or telling parents to come and change their child (unless the parents have requested to do this) or requiring an older sibling to change their sister/brother is likely to be a direct contravention of the Equality Act. Early years settings and schools should also be aware that knowingly leaving a child in a wet or soiled nappy, or pants, for prolonged periods places that child at risk of significant harm due to the increased risk of problems such as bladder infections. This could also be construed as child abuse.
The toolkit resources are available free of charge to all those involved with school-aged children including health professionals, school staff and parents.
Impact of The Right to Go
We know that a range of professionals and parents have used The Right to Go leaflet and extended toolkit to help improve continence management in educational settings. To date, these resources have been viewed via ERIC’s website more than 11,300 times and more than 2,500 printed copies have been sent out to both parents and professionals.
For parents specifically, the resources act as tools to empower them when communicating with school staff and health professionals about continence management. We have received positive feedback from parents on how school policies and procedures have been improved as a result of The Right to Go resources being adopted (Box 2).
Box 2. Using The Right To Go toolkit
One mother commented: “Earlier this year I was in a stalemate situation with my four-year-old’s school about support for her toileting problem. The school was frozen by a lack of extra funding to enable support such as a teaching assistant. I had to fight both to be heard and to be taken seriously – The Right to Go resource was invaluable for focusing everyone and getting a care plan in place.”
Timely identification of continence problems can often result in their quicker resolution, including shorter treatment time and improved outcomes - all of which have financial implications. Making school staff aware of childhood continence problems may encourage them to liaise with their local health professional about children who present with a bladder or bowel problem in school. This is important as parents may only acknowledge that a problem exists when their child starts school.
Our survey of schools revealed that a number of children and young people may be at risk because some school staff are unaware of the underlying causes of childhood wetting and soiling problems. As a result, some of these professionals provide care without adequate support, training and supervision, and without robust policies and governance arrangements in place to guide the support they provide to children. The toolkit highlights why children with additional toileting needs in school need a written care plan and support from staff who have an understanding of the child’s problem and appropriate training.
We launched The Right to Go resources in January 2013 and media coverage was generated across a range of medical trade, education and consumer media. We will be using a range of mechanisms, including feedback and surveys, to measure and evaluate the effectiveness of the resources.
ERIC and PromoCon will continue to develop and review the materials and it is hoped The Right to Go will be adopted by every school in the UK. This will help to ensure that all children with continence problems receive appropriate support in education settings, that parents are listened to and involved in developing care plans and that school staff are clear about their responsibilities and receive necessary training.
The Right to Go toolkit can be downloaded here. Other useful resources include PromoCon’s Managing Bowel and Bladder Problems in Schools and Early Years Settings: Guidelines for Good Practice, which is also available for download.
- Approximately 11% of children and young people in the UK who are aged 5-19 years have a continence problem
- Increasing numbers of children and young people with complex care needs and associated continence problems are attending mainstream school
- Poorly managed childhood bladder and bowel conditions can affect physical, emotional and psychological health and wellbeing
- 68% of children who have continence problems do not feel able to talk to school staff about it
- The Right to Go toolkit can help support schools to manage childhood continence problems
This article was a finalist in the 2013 Nursing Times Awards for Continence Promotion and Care. The deadline for this year’s awards has been extended to 16 May. For information on how to enter, go to ntawards.co.uk
Association of Teachers and Lecturers (2012) More Children Starting School Before they have been Toilet-trained - ATL/ERIC Survey. tinyurl.com/ATL-ERIC-continence
Butler RJ et al (2005) Nocturnal enuresis: a survey of parental coping strategies at 7 ½ years. Child: Care, Health and Development; 31: 659-667.
Education and Resources for Improving Childhood Continence (2013) Survey Reveals 40% of Children with Continence Problems Experience Bullying. tinyurl.com/eric-news-schools
Joinson C et al (2007) Psychological problems in children with bedwetting and combined (day and night) wetting: A UK Population-based study. Journal of Pediatric Psychology: 32; 605-616.
National Institute for Health and Care Excellence (2010a) Paediatric Continence Service: Commissioning Guide, Implementing NICE Guidance. London: NICE. tinyurl.com/paeds-continence-commissioning
National Institute for Health and Care Excellence (2010b) Constipation in Children and Young People: Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care. London: NICE. www.nice.org.uk/CG99