SOURCE: Adapted from Guide to Toilet Training (American Academy of Pediatrics)
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 he does succeed in this important aspect of self-care can make an enormous difference in his 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 he 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 he ready to learn?
Is he motivated at some level to take this next step?
If your child is in a resistant phase, is not ready to take on a new challenge, or does not yet feel the urge to behave “like other kids” in this way, you might take some extra time to prepare him mentally before starting the training process.
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.
It is also important to prepare yourself emotionally before you and your child embark on this experiment. Children with special needs often begin toilet training later than other children, frequently completing the process at age five or even 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, initially incomprehensible to others. Accidents will happen, of course, and you will need to draw on an extra dose of patience and humor when they occur. Lining up help from your spouse, relatives, or friends before you begin training—to spell you periodically as well as to help boost your morale—is a wise move for your child’s sake as well as your own.
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 and those with sight deficiencies experience a disadvantage at several stages of toilet training. First, they are unable to observe family members and peers using the toilet, so they cannot mimic their behavior. So many details of toilet or potty use—where the potty is in the bathroom, how the body is oriented to it as one sits down, how the urine and feces get into the potty, how one tears off and uses toilet paper—are simple to understand if a child can observe the process but difficult if she cannot. Without sight to help her, your child will need to rely more on language to understand how the process works. Therefore, you will probably want to wait a little longer to begin—until she is three or four years old (or even later, since language delays can accompany blindness)—so that she can fully comprehend what you are telling her.
When you are ready to introduce your visually impaired child to the concept of toilet use, start bringing her with you when you use the bathroom. Allow her to explore the bathroom and locate the toilet. (Be sure it’s well ventilated and smells pleasant so she will want to return.) Place her hands on your shoulders so she can feel you sitting on the toilet, explain what you are doing and why, and guide her hands to the toilet paper dispenser. Also show her the flush handle and the sink for hand washing. Once you have placed a potty in the bathroom, lead her to it, let her accustom herself to its presence, and keep it in the same place throughout the toilet-training process. Talk to her about toilet use at other times, too—pointing out that most of the people she knows use the toilet and that toilet use is a sign of being a big kid who can take care of herself.
Once she begins practicing potty use herself, you will need to keep the bathroom and the passage to it clear of obstacles. A musical potty that is activated when urine hits the bowl might make the learning process more fun. Teach her to feel the inner edge of the seat before tossing in the toilet paper and, if the child is a boy urinating standing up at a toilet, to position his body so he doesn’t urinate on the toilet. Finally, as she grows more comfortable with bathroom use, make a point of taking her to the bathroom at each public place you visit. By helping her familiarize herself with the wide variety of bathroom layouts and toilet styles, you will help build her self-confidence when away from home and prevent accidents. And don’t forget to reward her progress with praise, hugs, or a small, favorite treat.
Children who are deaf or have difficulty hearing may or may not find toilet training challenging, depending on their ability to communicate. 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. Children who do not yet have the ability to understand your signals and simple signs may not be ready for toilet training until they are somewhat older.
The key to training in these cases is to keep the process simple. When introducing the concept, emphasize the visual: Allow your child to observe you (and, even better, other children) 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, be sure to reward her with plenty of hugs, stars on a potty chart, or even candy or another small 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.
Children with cerebral palsy not only tend to be slow in developing bladder control, but may not have enough bladder awareness to begin toilet training at age two or three. If your child has cerebral palsy, she will need to be helped to develop an awareness that she needs to go (which may be signaled to you when you see her clutching her genitals or fidgeting anxiously) before she can begin toilet training. She will have to be able to delay urination until she is in position on the potty. She will need to remove her clothing and then hold herself on the potty (with supports) long enough to achieve success. Again, these challenges mean that it is usually best to wait to toilet-train 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 toilet-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 and Spinal Cord Injury
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. Resist the temptation to let things go when she resists or protests a little, and remain firm about the schedule or routine you have created—unless the experience becomes negative and your child becomes very resistant. Remember, her progress in this arena is especially significant if it increases her self-confidence and prepares her for more challenges. Give her all the information, attention, and support she needs to succeed.
Your experience toilet-training a toddler who is behaviorally, intellectually, or developmentally challenged will depend a great deal on your particular child’s temperament, behavior patterns, and coexisting conditions. In this arena more than any other, perhaps, the parents’ knowledge of a child’s strengths, weaknesses, tendencies, and interests will help her through the process as much as any general guide.
Toilet training can be particularly trying for parents of children who have intellectual or developmental disorders or who are behaviorally challenged—including those with autism, fetal alcohol syndrome (FAS), oppositional defiant disorder (ODD), and, in cases when it is diagnosed this early, attention deficit /hyperactivity disorder (ADHD). Many children with these conditions may not be strongly motivated, or sufficiently equipped, to respond to the social reinforcements that work so well with other children (“What a big boy!”), 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 are particularly sensitive to touch and other sensory input and become upset by the frequent pulling off and on of clothing, the physical closeness with an adult, and the unfamiliar surroundings of the bathroom. Simply getting across the concept of potty use can be complicated by the fact that some children with behavioral disorders 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 in your child and may lead to displays of temper, stubbornness, and refusal to cooperate.
Still, nearly all children with these conditions can be toilet-trained—though in some cases the process may take up to a year or even longer. Your first step, again, is to determine whether your child is ready to start training. There is no point in beginning until you see that he can stay dry for an hour or more at a time, has regular bowel movements, is aware that he is about to urinate or defecate, and dislikes being wet or soiled. It is also important to have your child examined by his pediatrician, since he may be at a higher risk for constipation or loose stools, which may interfere with training.
Once you have decided to begin, observe your child and consider carefully the specific traits, patterns of behavior, and obstacles that may impact his learning process. If he seems to dislike entering the bathroom, determine what the cause of his discomfort is—the smell of disinfectant? the cold floor? the flushing toilet?—and change or neutralize it if possible (change cleansers, put socks on his feet, move his potty away from the noisy toilet). If he does not overtly signal the need to urinate or defecate, does he pause just before voiding or otherwise behave in a way that will provide you with a cue? At what times, or how long after eating or drinking, does he usually urinate or defecate? What foods, toys, or other objects is he most passionate about? (These can be used as tangible potty-training rewards, which may prove more effective than praise.) How does he 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?
Once you have made the necessary adjustments in your child’s environment and your teaching style, it is time to start working toward his first success. Some parents like to begin the training process with actual potty use—putting their child on the potty at a likely time and rewarding him when he uses it. Others—particularly those with a child who resists entering the bathroom—may want to focus on preliminary steps first. They may start by rewarding the child for entering the bathroom, then for approaching the potty or toilet, then for sitting on it, and finally for using it. To make this process easier, and to avoid the physical closeness that your child may resist, consider letting him wear only his underwear at first, or even nothing below the waist. Handling clothing can be taught at the very end of the process, once the bathroom routine has been accepted as part of his day.
Your child is likely to be resistant to adopting this new habit. It’s important to insist, however—firmly but matter-of-factly—that he try. When accidents occur, point out that you disapprove, but don’t punish or criticize your child for making a mistake. If he is verbally challenged, be sure to stick to simple instructions such as “Wet! No!” As he gradually gets better at using the potty—motivated for the most part, perhaps, by the prospect of a tangible treat—your child’s love of routine will begin to work in your favor. He will expect to visit the bathroom at predictable times and may even become upset if this doesn’t happen. Until then, you will need to remind yourself how difficult this major step forward is for him. You should also think about how to find support for yourself as you search for the patience you will need to succeed. Both you and your child are embarking on a difficult developmental task.
Intellectual Disabilities and Developmental Disorders
Most children with a developmental delay, an intellectual disability, or a pervasive developmental disorder (for example, autism) can be toilet-trained, though the time it takes to achieve success ranges from a few months to a year or more. The process becomes easier as your child achieves at least a minimal level of verbal ability, is able to manage his clothes (perhaps with some help from you), and shows awareness of the need to go. As you introduce your child to the concept of potty use, be sure to keep your explanations very simple. Start by checking the state of his diaper or pants every hour or so and offering a one-word, nonjudgmental comment when he is wet (“Wet!”). Shake your head and then, after you change him, smile and say “Dry!” If his verbal skills are very limited, you might substitute a special gesture or sign for the words wet, dry, potty, need to go, and so on. Begin bringing him to the bathroom with you 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. After you’ve finished and are dressed, show him how happy you are and tell him “Dry!” If he has a favorite doll or stuffed animal, use it to play “potty,” demonstrating again how the potty is used.
When he is ready to begin using the potty, begin setting him on it at regular times—quite frequently at first (as frequently as you checked him for wetness earlier) and then gradually settling down to the times when he usually voids. Try to keep him on the potty for five or ten minutes at a time—keeping him company, reading to him, playing tapes of children’s music, and otherwise ensuring that he stays in place long enough to succeed. Once he does urinate into the potty, give him a big smile and say “Pee!” (or whatever word you have chosen for this event). Help him wipe off and then praise him with a happy “Dry!” and give him a treat. Food treats are often very effective and can be phased out once he has been trained. Eventually, with enough repetition, he will understand the connection.
Children with an intellectual disability or developmental delay are best toilet-trained one step at a time. Don’t expect your child to learn to signal or announce his need to go, pull down his pants, use the potty, wipe his bottom, and wash his hands all at once, the way his peers might. Toilet training will work best if you focus on the actual act of elimination first and address the other skills later. It is more important to keep him motivated than to achieve instant success.