Starting toilet training later in children with learnng disabilities can result in obstacles. A five step approch was developed to achieve bladder and bowel control
June Rogers MBE , RN, RSCN, BA, MSc, is team director, PromoCon.
Rogers J (2010) One step at a time: how to toilet train children with learning disabilities. Nursing Times; 106: 47, early online publication
Toilet training children with learning difficulties can present challenges and requires careful assessment and management. This article examines strategies for toilet training using a five step approach to achieve bladder and bowel control.
KeywordsContinence, Learning difficulties, Assessment
- This article has been double blind peer reviewed
- Late toilet training may be associated with an increase in urinary incontinence in children.
- Late toilet training of children with a learning difficulty may result in obstacles related to the child’s reluctance to engage with the process, rather than an inability to learn to control their bladder and bowel.
- The decision to start toilet training a child with a learning difficulty should take into account the parents’ expectations of how independent the child will be, and the child’s physiological development.
Control over bladder and bowel function is an important developmental milestone in all cultures. However, the rate at which it is achieved across different populations varies and is influenced by a number of factors such as genetic, neurodevelopment and social influences (Hackett et al, 2001). A longitudinal study by Jansson et al (2000) found the median age for daytime dryness was 3.5 years and four years for night time dryness with no real difference between boys and girls. Bladder sensation was reported in 31% of two year olds, 79% of three year olds and 100% of four year olds, with a median bladder capacity of 67 ml, 123 ml, and 140 ml at ages one, three and six years respectively.
There has been a trend over the last 60 years for later toilet training from around 18 months to two years of age to currently around three years of age and this has been linked to an increase in dysfunctional voiding problems (Bakker and Wyndaele, 2000). Barone et al (2009) identified that the majority of children diagnosed with daytime incontinence had started toilet training later compared to a control group of children without any urinary symptoms. They concluded that children should be toilet trained as soon as they were identified as being ready, and delaying this beyond the age of 32 months increased the risk for urge incontinence.
This supported the findings of an earlier study suggesting that toilet training helps children learn to completely empty their bladders, which in turn reduces the risk of urinary tract infection (Jansson et al, 2000). It is recommended that in order to reduce the risk of children developing dysfunctional bladders, toilet training should start early (Hellstrom and Sillen, 2001).
It is important to assess both physical and physiological development to identify if the child is ready for toilet training. This includes their ability to sit - with or without support - and evidence of bladder and bowel maturity. This is defined as a bladder that has developed sufficient capacity to enable the child to stay dry for at least one and a half to two hours, and bowel function that is not affected by toddler diarrhoea or constipation.
Toilet training is often influenced by socio-emotional readiness such as the child requesting to wear pants or external factors such as starting nursery school. Many parents rely solely on external triggers before starting toilet training, which often means the process starts late and there is pressure to complete it quickly before their child starts nursery.
Children with learning difficulties
The issue for children with learning difficulties is that relying solely on external trigger factors, such as the child showing an interest, invariably leads either to a delay in starting, or not attempting toilet training at all. All children benefit from a structured toilet training routine, which includes sitting on the potty or toilet as a normal activity, and from formal training when they are physically ready, which is typically between 24 and 30 months. Indicators of readiness include the child staying dry for increasing periods of time, and being dry after a daytime nap.
There is some evidence that changing to washable training pants, particularly if the child is over three years old, helps speed up the process by raising the child’s awareness and providing negative feedback during wetting episodes (Simon and Thompson, 2006; Tarbox et al, 2004). It is important to check for underlying constipation if the child appears to struggle with toilet training as there is evidence that this is linked to a delay in the process (Schonwald et al, 2004).
Toilet training steps
Following a fact finding trip to Australia in 2005 to review paediatric continence services and share ideas, I made links with the Continence Foundation of Australia (CFA). In 2008, a request was made by the CFA to PromoCon to see if we would collaborate in the development of a resource for parents of children with learning difficulties to help them with toilet training.
Toilet training is a skill that can be broken into a number of steps, and by addressing one step at a time it makes the whole process easier and more manageable for the family. Putting children with learning difficulties on a toilet skill development programme enables them to develop skills they need to be toilet trained. Once those skills are in place a more formal toilet training programme involving removing day time nappies and scheduled sitting on the potty or toilet, can begin.
One Step at a Time (CFA, 2010) was developed and is used successfully with families of children with a whole range of learning difficulties to help them become toilet trained. The steps are summarised in Box 1.
Step 1: setting the scene
This step enables the child to learn new skills by introducing and encouraging modifications to the routine of nappy changing. It involves establishing healthy eating and drinking habits and sitting the child on the potty or toilet at regular intervals during the day. Changing the child in the bathroom helps them to be more aware of the connection between urine and faeces and the toilet. It is suggested that children who are able to stand unsupported are changed standing up so they become more involved with the process. Learning about the difference between wet and dry is also introduced at this stage.
Step 2: Developing physical skills
This step focuses on the physical skills required to use the toilet including sitting on the toilet, pulling pants up and down and also developing an understanding of what the toilet is for including flushing and, washing and drying hands. At this stage the need for further support, such as aids to help sitting or transferring to the toilet should be identified and referral to an occupational therapist or physiotherapist may be required.
Step 3: Raising awareness
This step involves identifying children’s habits - such as how long they can stay dry and if there is a regular time when they have their bowels opened. To enable the family to do this it is suggested they place some sheets of folded kitchen paper (one that does not disintegrate when wet) into the child’s nappy at the first nappy change of the day, then, at hourly intervals throughout the day to check and record if it is wet or dry (Rogers 2004) Kitchen paper is useful because nappies will not feel wet if a small amount of urine is passed and it can also be difficult to detect if the child has passed urine. If the pad of kitchen roll is wet or soiled it should be changed. If the child is able to stay dry for one and a half to two hours and has no underlying bowel problems such as constipation, plans can be made to move the child out of disposable nappies into washable underwear or trainer pants.
Step 4: Using the toilet
At this stage the child is expected to pass urine and stools in the toilet. The necessary skills have been practiced in step 2 so the child should cooperate and be happy to sit on the toilet and attempt to pull pants up and down. Other skills introduced at this stage include, encouraging the child to wipe his or her own bottom and to use unfamiliar toilets. Some parents are unsure whether to use a potty before moving on to the toilet. This decision depends on the child and whether using a potty first will cause confusion or the child is likely to have difficulty transferring skills to the toilet at a later stage. In these circumstances it is suggested that the child goes directly to using the toilet.
Step 5: Night time control
Once dry during the day some children will spontaneously become dry at night within a few months. However a number of children may persist with nocturnal enuresis (bedwetting) for some time. Most children will be dry at night by the time they are between five and six years old, but we know there are some children who have a persistent problem and will require treatment. In these cases referral to the local enuresis service would be appropriate – there is no reason why children with learning difficulties, who have been reliably dry in the day should not be able to become dry at night.
There is debate about the best time to start toilet training. In some Asian and African cultures, toilet training is attempted with infants, while training between two and three years is more typical in Western cultures. It is now recognised that infant voiding is not merely a spinal reflex, as the sensation of bladder filling is relayed to the brain. However, the ability of the brain to inhibit bladder contractions, and to achieve coordinated bladder contraction with sphincter relaxation, matures over time.
While there is a concern that later toilet training may be associated with an increase in urinary incontinence in children, no controlled studies on early versus late toilet training exist to evaluate this hypothesis. Clinical experience suggests that starting toilet training later in a child with a learning difficulty often results in obstacles. These may be related to the child’s behaviour and reluctance to engage with the process rather than an inability to learn to control their bladder and bowel. Examples of problems include children with autism who refuse to void anywhere except a particular toilet, or those who holds on to their stool until a nappy is put on.
The decision to start toilet training a child with a learning difficulty should take into account not only the parents’ expectations of how independent the child will be in terms of toileting, but also the child’s physiological development in terms of maturing bladder and bowel so that a realistic time scale for toilet training can be implemented.
Box 1. Steps for toilet training
- Step 1: Setting the scene
- Step 2: Developing the skills needed
- Step 3: Raising awareness
- Step 4: Using the toilet
- Step 5: night time control
PromoCon provides a national service, working as part of Disabled Living, Manchester, to improve the life for all people with bladder or bowel problems by offering product information, advice and practical solutions to both professionals and the general public. PromoCon runs a confidential helpline and has a range of free downloadable booklets and leaflets.
Bakker E, Wyndaele JJ (2000) Changes in the toilet training of children during the last 60 years: the cause of an increase in lower urinary tract dysfunction? British Journal of Urology International; 86:248-52.
Barone JG e al (2009) Later toilet training is associated with urge incontinence in children. Journal of Pediatric Urology; 5: 6, 458-61.
Hackett R et al (2001) Enuresis and encopresis in a south Indian population of children. Child care Health and Development; 27: 1, 35-46.
Helstrom AL, Sillen U (2001) Early potty training advantageous in bladder dysfunction. Decreases the risk of urinary infection. Lakartidningen; 98: 28-29, 3216-3219.
Jansson UB et al (2000)Voiding pattern in healthy children 0 to 3 years old: a longitudinal study. Journal of Urology;164: 6, 2050-4.
Continence Foundation of Australia (2010) One Step at a time- a parents guide to toilet skills for children with special needs.
Rogers J (2004) Talk about going to the toilet. Manchester: PromoCon.
Schonwald A et al (2004) Factors Associated with Difficult Toilet Training. Pediatrics; 113: 1753-1757.
Simon JL, Thompson RH (2006) The effects of Undergarment Type on the Urinary Continence of Toddlers. Journal of Applied Behavior Analysis; 39: 3, 363-368.
Tarbox RS et al (2004) Extended diaper wearing: effects on continence in and out of the diaper. Journal of Applied Behavior Analysis; 37: 1, 97-100.
One step at a time: how to toilet train children with learning disabilities