TOILETING CHILDREN WITH LEARNING DISABILITIES

Deirdre O'Mahoney, Continence Advisor for Learning Disabilities, Continence Promotion Unit, Dr Steeven's Hospital, offers advice to parents and carers on toilet training.

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INTRODUCTION

The age at which a child with learning disabilities gains toileting skills varies greatly. This is often of great concern to parents, who tend to toilet-train children too early or to delay it because of the child’s special needs. By observing a child’s toilet-training readiness, training can be introduced when appropriate, making success more likely.

Gaining continence depends upon the interaction of two processes: the maturation of the central nervous system and the socialisation of the child. The child has to be able to recognise the need to pass urine, perceive the signal correctly, and postpone micturition until an appropriate time. Children with special needs may be slow to develop bowel and bladder control because of lack of muscle control, delayed maturation of the central nervous system, difficulty in asking for attention, or feeling insecure on the potty. A child will also need to learn to open doors, manage clothing, use toilet paper and flush a toilet.

IS A CHILD READY FOR TOILET-TRAINING

Physical development

  • Child can sit with or without support (a non-mobile child).
  • Child attempts to squat without losing balance; is beginning to walk independently (a mobile child).

Cognitive development

  • Child will search for a hidden toy; this my be by eye-pointing.
  • Child can copy an action or engages in make-believe play.

Language development

  • Child can understand a simple request.
  • Child is able to communicate needs by words, signs or gestures.

Toileting readiness

  • Child shows awareness of being wet or soiled.
  • Child is able to stay dry for at least one hour.
  • Child is aware of use of toilet/potty.

The above list is a guide only, and is an indication of a child’s development regardless of age. If a child shows most of these skills, she/he is ready for toilet-training.

HOW TO START
  1. Introduce the idea of toilet training to a child by play, i.e. sitting teddy on the potty; getting the child to sit on the potty with his/her nappy on.
  2. Have an open-door policy in the bathroom of the family home–children learn by watching others.
  3. Use language the child can understand, e.g. ‘wee’, ‘poo’–use the same terms consistently.
  4. Sit the child on the potty after meals, gradually lengthening the time from one to five minutes. Make toilet-training fun. Use books or toys to encourage sitting and give plenty of praise.
  5. Get the child to choose their potty–perhaps in the shape of a car or teddy. The use of a ‘musical’ potty may be a good idea, as it provides an instant reward when the child ‘pees’. If the toilet is used, purchase an insert-seat and ensure that the child’s feet rest on a footstool–for security and to aid muscle use.
  6. For a fortnight before starting toilet-training in earnest–while getting the child used to the idea–make a note of the frequency and possible pattern of the child’s wetness/dryness and ‘pooing’. Increasing fluids may be useful; this gives more opportunities to use the potty.
STARTING ‘FOR REAL’
  1. Choose a convenient time–summertime may be best for drying clothes.
  2. Remove the child’s nappy during the daytime, as the absorbency of disposable nappies prevents the child from feeling wet or being aware of body functions. Use underpants, perhaps patterned ones the child has chosen him/herself- Continue to use night-time nappies until day control is well established.
  3. Initially, put the child on the potty every hour, for a maximum of five minutes. Extend the time interval as accidents occur less frequently, until they are using the toilet every 3-4 hours.
  4. Have a structured programme–day control first, then bowel control, and finally night control.
  5. Do not scold if there is an accident; praise and give an appropriate reward when the child performs on the toilet/potty.
GAINING BOWEL CONTROL

Children take longer to gain bowel control. Initially they may hold-back, not using the toilet, and may get a bit constipated. To avoid this, encourage fluids and fruit and vegetables. The natural mechanism, known as the gastro-colic reflex, which stimulates the urge to defecate works twenty minutes to one hour after a main meal. Thus, encouraging the child to sit after breakfast and dinner gives the best chance of having a bowel movement. (In research carried out in England (Parker 1986), parents of children with special needs reported that even if full toilet training was not achieved, placing their child on the toilet lessened constipation and incontinent episodes.)

BEHAVIOURAL APPROACHES

Rewarding desired behaviour will cause that behaviour to occur more often; this is especially important in toilet-training with children with learning disabilities. Rewards can be praise, a hug or kiss, or a small piece of cheese or fruit. The strongest reward for the individual child should be given, and consistently; the reward should be withheld if the desired behaviour does not occur.

CONCLUSION

Children with special needs feel secure with routine for learning. Time perception is difficult for children with learning disabilities; repetition is very important if you want them to perform any action. Reassurance must be constant, particularly if accidents occur.

Be positive, optimistic–and patient. Continue the toilet-training programme for three months. If there is any improvement, continue the programme. If there appears to be no improvement, take a break for a few weeks; then try again.

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