Toilet-Training A Child with Toilet-Training A Child with a Developmental Disability: a Developmental Disability:

A Family-Focused, Low Intensity A Family-Focused, Low Intensity

Approach Approach

Susan Hepburn, Ph.D.Susan Hepburn, Ph.D.

Clinical PsychologistClinical PsychologistAsst. Professor/Director of ResearchAsst. Professor/Director of Research

JFK Partners/Dept. of PsychiatryJFK Partners/Dept. of PsychiatryUniversity of Colorado at Denver and Health University of Colorado at Denver and Health

SciencesSciences

AcknowledgmentsAcknowledgments Association of University Centers for Association of University Centers for

Excellence in Developmental Disabilities Excellence in Developmental Disabilities (UCEDD)/JFK Partners(UCEDD)/JFK Partners

Developmental PathwaysDevelopmental Pathways

Teachers and administrators in Cherry Creek Teachers and administrators in Cherry Creek School District and Littleton Public SchoolsSchool District and Littleton Public Schools

Families of children who have participated in Families of children who have participated in individual and group toilet-training individual and group toilet-training interventionsinterventions

This talk is dedicated to This talk is dedicated to Nathaniel Roberts, Nathaniel Roberts,

a dear boy, who taught us much a dear boy, who taught us much about social motivation about social motivation

and the joys of independence.and the joys of independence.

We develop this work in his memory.We develop this work in his memory.

OverviewOverview Part I: Philosophy and Core PrinciplesPart I: Philosophy and Core Principles

Part II: Getting Ready: Changes we Make While Part II: Getting Ready: Changes we Make While the Child is Still in Diapers or Pull-upsthe Child is Still in Diapers or Pull-ups

Part III: Practicing in Routines and Building HabitsPart III: Practicing in Routines and Building Habits

Part IV: Working on Pooping in the ToiletPart IV: Working on Pooping in the Toilet

Part V: Getting Rid of Diapers and Pull-upsPart V: Getting Rid of Diapers and Pull-ups

Part VI: Reflect on Your ProgressPart VI: Reflect on Your Progress

Part I:Part I:Philosophy Philosophy

and and Core PrinciplesCore Principles

PhilosophyPhilosophy

PatiencePatience

PersistencePersistence

HumorHumor

CreativityCreativity

““Toilet training in less than a year”Toilet training in less than a year”

““It’s a marathon, It’s a marathon, not a sprint”not a sprint”

-- Gary -- Gary Heffner,Heffner,

father father andand

advocateadvocate

Many people Many people believe…believe…

1. Your child has to be “ready”1. Your child has to be “ready”2. More trips is always better.2. More trips is always better.3. You have to get rid of the diapers to make 3. You have to get rid of the diapers to make progress. progress.4. Children need to be able “tell someone” 4. Children need to be able “tell someone” that they that they have to use the bathroom as a first step. have to use the bathroom as a first step.

HOWEVER….

Core Principle ICore Principle I We don’t hold tightly to “readiness” We don’t hold tightly to “readiness”

criteriacriteria

We think that children learn through practice We think that children learn through practice within their natural routines and don’t within their natural routines and don’t necessarily have to be “ready” for us to make necessarily have to be “ready” for us to make the toileting issues less stressful for the family.the toileting issues less stressful for the family.

We use a “slow and steady” approach, allowing We use a “slow and steady” approach, allowing us to adjust our strategies depending upon the us to adjust our strategies depending upon the child’s progress.child’s progress.

We emphasize the importance of the We emphasize the importance of the parents parents being ready – particularly when it comes time being ready – particularly when it comes time to remove the diapers or pullups.to remove the diapers or pullups.

There is always something we There is always something we can do to get to the next can do to get to the next

step….step…. Within your regular routinesWithin your regular routines

Without removing the diapers or pull-Without removing the diapers or pull-upsups

For most children, it makes sense to For most children, it makes sense to start toilet training when they have a start toilet training when they have a developmental age of about 15 developmental age of about 15 monthsmonths

Core Principles Core Principles IIII

More is not always better.More is not always better. Too many unsuccessful trips to the bathroom Too many unsuccessful trips to the bathroom

may actually slow progress.may actually slow progress.

If a child is overwhelmed by the training If a child is overwhelmed by the training process, problem behaviors and resistance will process, problem behaviors and resistance will occur.occur.

Parents tell us that intensive approaches are Parents tell us that intensive approaches are difficult and stressful.difficult and stressful.

Core Principles IIICore Principles III Getting rid of the diapers happens towards the Getting rid of the diapers happens towards the

end of the processend of the process – most of the training is done – most of the training is done with the child still in protective gear.with the child still in protective gear.

For a child who doesn’t “feel” the wet diaper or become For a child who doesn’t “feel” the wet diaper or become uncomfortable being soiled, removing the diapers uncomfortable being soiled, removing the diapers doesn’t speed up the training process.doesn’t speed up the training process.

Several steps and concepts need to be mastered before Several steps and concepts need to be mastered before diapers should be removed.diapers should be removed.

By minimizing the amount of messes parents deal with, By minimizing the amount of messes parents deal with, we hope to reduce the stress of the process.we hope to reduce the stress of the process.

Core Principles IVCore Principles IV

Teaching the child to communicateTeaching the child to communicate that he that he or she needs to go the bathroom often or she needs to go the bathroom often comes comes toward the endtoward the end of the training of the training program.program. Communication is always built into the routine Communication is always built into the routine

and is practiced, but not “required”and is practiced, but not “required”

It is often helpful to have a nonverbal way of It is often helpful to have a nonverbal way of signaling the need to go – although we can’t signaling the need to go – although we can’t prompt a child to verbally request the bathroom, prompt a child to verbally request the bathroom, we can prompt a gesture or picture exchangewe can prompt a gesture or picture exchange

Part II:Part II:“Getting Ready”“Getting Ready”

First Steps First Steps

in almost anyin almost any

toilet-training interventiontoilet-training intervention

1. Observe1. Observe Make lists of Make lists of

foods/drinks your child foods/drinks your child usually consumesusually consumes

Note the approximate Note the approximate times of day the child times of day the child is eating/drinkingis eating/drinking

Look for anything Look for anything unusual in frequency or unusual in frequency or consistency of child’s consistency of child’s pee and pooppee and poop

Are there any behavioral Are there any behavioral signs that your child needs signs that your child needs

to go?to go?

2. Ask the Pediatrician2. Ask the Pediatrician

Dietary Dietary recommendationsrecommendations

Are supplements Are supplements needed to prevent needed to prevent constipation?constipation?

Any possible GI Any possible GI issues or treatments issues or treatments to consider?to consider?

3. Consider Dietary 3. Consider Dietary ChangesChanges

Lots of fluid: water Lots of fluid: water or juice are best!!or juice are best!!

Lots of fiber: Lots of fiber:

Age plus 5 grams!Age plus 5 grams!

spread across 3 spread across 3 mealsmeals

Less dairyLess dairy

4. Consider small changes in daily 4. Consider small changes in daily habitshabits

Dress child in easy to remove clothingDress child in easy to remove clothing

Change as quickly as possibleChange as quickly as possible

If possible, change diapers in (or near) bathroomIf possible, change diapers in (or near) bathroom

Show child that waste goes in toilet Show child that waste goes in toilet

Have child flush and wash hands at diaper Have child flush and wash hands at diaper changeschanges

5. Interactions with Your Child5. Interactions with Your Child

Decide on your toileting words and use them Decide on your toileting words and use them every day across people and placesevery day across people and places

Be very matter-of-fact and positive about using Be very matter-of-fact and positive about using the toiletthe toilet

Be very positive about their efforts and Be very positive about their efforts and cooperation – do not emphasize producing into cooperation – do not emphasize producing into the toilet, but emphasize willingness to trythe toilet, but emphasize willingness to try

Try to make sure that something good or fun Try to make sure that something good or fun happens when you leave the bathroomhappens when you leave the bathroom

6. Showing and Telling Kids About 6. Showing and Telling Kids About ToiletingToileting

Allow child to watch mom or dad or siblingsAllow child to watch mom or dad or siblings

Look at toileting books and videos togetherLook at toileting books and videos together

Listen to toileting songs togetherListen to toileting songs together

Teach toileting through playTeach toileting through play

Make a homemade book about toiletingMake a homemade book about toileting

Make a home movie about toiletingMake a home movie about toileting

7. 7. Think About Rewards for ParticipationThink About Rewards for Participation

A fun activity – particularly good if it is natural to A fun activity – particularly good if it is natural to the child’s schedule – for example – going outside the child’s schedule – for example – going outside to playto play

Special food or drinkSpecial food or drink Special toysSpecial toys Special sensory experiencesSpecial sensory experiences Target practice (cheerios, sinkems, wax paper)Target practice (cheerios, sinkems, wax paper)

To improve the power of your rewards: try to limit To improve the power of your rewards: try to limit access only to toileting times!!!access only to toileting times!!!

8. Set Up Your Bathroom 8. Set Up Your Bathroom Make it a pleasant place to be (smells good, Make it a pleasant place to be (smells good,

warm, perhaps music is playing)warm, perhaps music is playing)

Make sure the child is comfortable on the toilet Make sure the child is comfortable on the toilet and if needed, get a potty chair insertand if needed, get a potty chair insert

Provide foot stool or other way for child to feel Provide foot stool or other way for child to feel stable while seatedstable while seated

Make sure your rewards are nearby Make sure your rewards are nearby

Put up some visual supportsPut up some visual supports

More on Visual SupportsMore on Visual Supports

Visual supports for Visual supports for the overall routine the overall routine and when you will and when you will visit the toilet visit the toilet

Visual supports for Visual supports for the steps within the steps within the routinethe routine

Transitional objectTransitional object

Visual remindersVisual reminders

Visual supports to Visual supports to clarify how long he clarify how long he has to sit therehas to sit there

Visual supports to Visual supports to show what will show what will happen when it’s happen when it’s overover

9. Think about who can help 9. Think about who can help out….out….

Spouse/partnerSpouse/partner SchoolSchool Daycare providersDaycare providers GrandparentsGrandparents Respite staffRespite staff

And talk to them about what you are trying to do.

Part III: Part III: Practicing In Routines Practicing In Routines

and Building Habitsand Building Habits

How to Trip TrainHow to Trip Train

You set the scheduleYou set the schedule

You train the child’s body to go during You train the child’s body to go during your scheduleyour schedule

For peeing: trip is 10-30 seconds on For peeing: trip is 10-30 seconds on toilettoilet

For pooping: “Sit for Six”For pooping: “Sit for Six”

**for children with low muscle tone, they **for children with low muscle tone, they may need longer to pee or to poopmay need longer to pee or to poop

Trip Training: Time to Go!Trip Training: Time to Go! Within the flow of your regular routine, while child is Within the flow of your regular routine, while child is

still wearing diapers or pull-ups: prompt child to go still wearing diapers or pull-ups: prompt child to go to the toilet; encourage but don’t require that child to the toilet; encourage but don’t require that child communicate urge to go communicate urge to go

Request that child sit for a very brief time, but don’t Request that child sit for a very brief time, but don’t force it! Try to distract with songs or favorite toys force it! Try to distract with songs or favorite toys while practicing sittingwhile practicing sitting

Complete the entire routine and after drying hands – Complete the entire routine and after drying hands – give reward (or go to a cool next activity) simply for give reward (or go to a cool next activity) simply for cooperatingcooperating

If child actually If voids If child actually If voids big reward big reward

Choosing the Times to GoChoosing the Times to Go

DO CHOOSE:DO CHOOSE: A clear and A clear and

predictable activity predictable activity for the “before” for the “before” time, such as time, such as dinner, or coming in dinner, or coming in from outsidefrom outside

A fun activity for A fun activity for the “after” timethe “after” time

DO NOT CHOOSE:DO NOT CHOOSE: To interrupt the To interrupt the

child’s favorite or child’s favorite or preferred activities, preferred activities, such as tv or such as tv or computer timecomputer time

Times in the day that Times in the day that are too hectic for you are too hectic for you to realistically doto realistically do

So, we have to do 3 things:So, we have to do 3 things:1.1. Try to predict how long between Try to predict how long between

input (drink) and output (pee)input (drink) and output (pee)

2.2. Pick natural transitions – or times Pick natural transitions – or times when child is already changing from when child is already changing from one activity to another – for one activity to another – for example, coming in the door from example, coming in the door from schoolschool

3.3. Practice making trips to the Practice making trips to the bathroom within routines no more bathroom within routines no more than 3-6 times per day.than 3-6 times per day.

A Toileting RoutineA Toileting Routine Regular routine or transition (such as coming Regular routine or transition (such as coming

inside from school)inside from school)

Visual reminder or physical cue to go to the Visual reminder or physical cue to go to the bathroombathroom

Quick 30 second to 1-minute trip, following all the Quick 30 second to 1-minute trip, following all the steps of the routine whether or not he has steps of the routine whether or not he has produced anythingproduced anything

Leave the bathroom and something good or fun Leave the bathroom and something good or fun happenshappens

Practice, persist, and Practice, persist, and perseverepersevere

Give the routines time to take holdGive the routines time to take hold

Be as consistent as you possibly canBe as consistent as you possibly can

Forgive yourself and others when it just Forgive yourself and others when it just can’t be donecan’t be done

Remind yourself that this is a hard skill Remind yourself that this is a hard skill and will come with time and practiceand will come with time and practice

Change up the rewardsChange up the rewards

Example of steps of a Example of steps of a routineroutine

Walk to bathroomWalk to bathroom Pull down pants/underwearPull down pants/underwear Sit on toiletSit on toilet Go in toiletGo in toilet WipeWipe Stand up and dressStand up and dress FlushFlush Wash handsWash hands Go playGo play

Another tip….Another tip….

Look for times when your child is Look for times when your child is really motivated for something (such really motivated for something (such as wanting to watch a favorite TV as wanting to watch a favorite TV show) and develop a routine:show) and develop a routine:

FIRST POTTY ……..THEN TVFIRST POTTY ……..THEN TV

Part IV: Part IV: Working on Pooping Working on Pooping

in the Toiletin the Toilet

StepsSteps Continue to monitor and treat any constipation issuesContinue to monitor and treat any constipation issues

If child has low muscle tone, talk to an OT or PT about If child has low muscle tone, talk to an OT or PT about exercises that can strengthen core muscles.exercises that can strengthen core muscles.

Choose 1 toilet trip per day that will be a “Poop Trip”Choose 1 toilet trip per day that will be a “Poop Trip” The child will be asked to stay a few minutes longer (about The child will be asked to stay a few minutes longer (about

4-6 minutes)4-6 minutes) The adult will need to be there (at least in the beginning).The adult will need to be there (at least in the beginning). Choose a very special reward for pooping.Choose a very special reward for pooping.

Some Additions to Some Additions to the Routine for Poop Tripsthe Routine for Poop Trips

Consider exercise just before the tripConsider exercise just before the trip

Consider taking the child’s hand and Consider taking the child’s hand and applying pressure to their belly to focus applying pressure to their belly to focus their attention on that areatheir attention on that area

Try very hard to interrupt accidents and Try very hard to interrupt accidents and get them onto the toilet if already get them onto the toilet if already poopingpooping If they get a tiny bit in – it’s a success!!If they get a tiny bit in – it’s a success!!

If a child is afraid of pooping in the If a child is afraid of pooping in the toilettoilet

We often do increased work on the social stories, We often do increased work on the social stories, home movies, and other ways to help them to get home movies, and other ways to help them to get used to the ideaused to the idea

We gently encourage them and support them to We gently encourage them and support them to face their fearsface their fears

We often start with small steps and help them to We often start with small steps and help them to desensitize to what’s scarydesensitize to what’s scary

Sometimes we can provide some environmental Sometimes we can provide some environmental supports to reduce loud noises and other scary supports to reduce loud noises and other scary partsparts

Part V: Part V: Getting Rid of Getting Rid of

Diapers and Pull-UpsDiapers and Pull-Ups

When do I get rid of the When do I get rid of the diapers?diapers?

No right or wrong answer hereNo right or wrong answer here

Varies a lot by child’s styleVaries a lot by child’s style

Some need us to make a clean breakSome need us to make a clean break

Others maintain them throughout 75% of the Others maintain them throughout 75% of the training processtraining process

For many children with sensory and/or motor For many children with sensory and/or motor issues: issues: Getting rid of the diapers may Getting rid of the diapers may notnot help the child help the child

to learn the skill more quickly; to learn the skill more quickly; BUT …. can actually increased stress and BUT …. can actually increased stress and

frustrationfrustration

We want to get rid of the diapers We want to get rid of the diapers when:when:

1)1) The child is cooperating with the routine, and has The child is cooperating with the routine, and has

successfully urinated in the toilet several times.successfully urinated in the toilet several times.

2)2) We can commit 3 weeks to really good consistency and We can commit 3 weeks to really good consistency and follow-up.follow-up.

3)3) We know there will be accidents and we are prepared We know there will be accidents and we are prepared to try to use those accidents as chances to teach the to try to use those accidents as chances to teach the skill.skill.

4)4) If at all possible, best to do while child is in school or a If at all possible, best to do while child is in school or a program where others are also willing to make this program where others are also willing to make this step. This helps the child learn the skill more fully and step. This helps the child learn the skill more fully and transfer it to other places more easily.transfer it to other places more easily.

Choose a Good Time in Your Family’s Choose a Good Time in Your Family’s LifeLife

Consider: your work schedule, other children, Consider: your work schedule, other children, holidays, special events and other demands that holidays, special events and other demands that may make it easier or harder to beginmay make it easier or harder to begin

Remember: First 3 weeks are very important and Remember: First 3 weeks are very important and most labor intensive!most labor intensive!

It has to work for the family – if we can persist It has to work for the family – if we can persist through this difficult phase we are more likely to through this difficult phase we are more likely to be successful!!be successful!!

Decide How to Handle AccidentsDecide How to Handle Accidents

Do not punish or scold!!Do not punish or scold!!

Option 1: Gentle correction and changeOption 1: Gentle correction and change

Option 2: Immediately place on toilet and Option 2: Immediately place on toilet and R+ if just the tiniest bit gets inR+ if just the tiniest bit gets in

Option 3: Allow to feel sensation and Option 3: Allow to feel sensation and involve in clean-upinvolve in clean-up

Remember, many kids Remember, many kids with developmental with developmental

disabilities need longer disabilities need longer to mature into being dry to mature into being dry

at night.at night.

When we remove the diapers When we remove the diapers during the day, we often keep during the day, we often keep

them on at night.them on at night.

Part VI: Part VI: Reflect on Your ProgressReflect on Your Progress

And Make Changes As NeededAnd Make Changes As Needed

After 3-6 weeks: How’s it After 3-6 weeks: How’s it going? going?

Do you need to modify your Do you need to modify your approach?approach?

Options for making changes Options for making changes after after

3-6 weeks of trip-training3-6 weeks of trip-training Play with the schedulePlay with the schedule Change up the rewardsChange up the rewards Change the social context Change the social context Change dietChange diet Find another way to teach the connection – Find another way to teach the connection –

music, videos, modelling, playmusic, videos, modelling, play

Once you’ve decided on the changes, give them 3-6 weeks to work and re-evaluate. Are you seeing improvement?

If you are approaching 3 months of trip-If you are approaching 3 months of trip-training and not seeing a lot of change…training and not seeing a lot of change…

Sometimes….we pause, take a break from Sometimes….we pause, take a break from working on this skill and come back to it a little working on this skill and come back to it a little later, preserving 1 routine a day if at all possiblelater, preserving 1 routine a day if at all possible

Sometimes…we identify a problem and provide Sometimes…we identify a problem and provide some new instructional component or change in some new instructional component or change in our teaching methodsour teaching methods

Sometimes….we move to a more intensive Sometimes….we move to a more intensive intervention, like eliminating the diapers and intervention, like eliminating the diapers and learning through accidentslearning through accidents

Sometimes….we decide to stay the course. It all Sometimes….we decide to stay the course. It all depends on the child’s style and all of the other depends on the child’s style and all of the other variables that affect this skill.variables that affect this skill.

ConclusionConclusion