Rhode Island Medical Home Portal - Toilet Training for CYSHCN

Primary care clinicians frequently address questions about potty training in the general pediatric population and excellent resources address most caregivers’ concerns; however, providing guidance about toilet training for children with physical, intellectual, or sensory delays or disabilities is more challenging and most clinicians lack related training. The following provides information for clinicians to determine when a child with special health care needs may be ready to toilet train and gives guidance about toilet training at school and home. Clinicians should also refer families and caregivers to this excellent resource from the American Academy of Pediatrics: Toilet Training Children with Special Needs (AAP).

Determining Readiness

Margaret Miller/Science Photo Library

The medical home clinician helps to determine if the family considers toilet training a goal and, if so, when they would like to focus on it. It is important to touch on this issue early (when the child is 2 to 3 years old) and indicate to the family that while achieving continence might take time, it is likely something their child can accomplish. General indications that the child is ready to toilet train include:

Diapers are typically dry for at least 2 hours.
The child can feel the difference between being dry or wet/soiled. Sometimes the child has to be changed into regular underwear instead of absorbent diapers or pull-ups for a few days to assess this.
The child is capable of delaying urination or stooling until reaching the potty, with help if needed.
The child is motivated to use the potty and to help remove clothing when possible.
The child is commonly >4 1/2 years.
The child displays no fears of being in, on, or around the bathroom. If fears exist, a behavioral desensitization program needs to be done first.
All medical or physical barriers (e.g., constipation) have been addressed.

Many parents think that their child must be able to communicate verbally in order to toilet train; however, being able to communicate the need to be taken to the bathroom and the functional ability to independently toilet are NOT required. Families can also communicate using signals/hand signs for going to the potty.

Natural Schedule

The child's natural patterns are monitored for several weeks. Subsequently, the teacher or parent takes the child to the toilet on a pattern to match his or her natural rhythms. If the child does not urinate or defecate at that time, toileting is repeated every 15 minutes until the child either goes in the toilet or the diaper. The next time for toilet sitting is the next “high probability” time. Positive reinforcement is given for any output into the toilet and for dry diapers.

If the natural schedule approach does not work, timed toilet sitting on an hourly schedule, particularly after meals, can help children stay dry and clean.

Toilet Training as a School Goal

Toilet training often begins as a school goal and, once successful, transitions to the home environment. A behavior program is structured where the child is encouraged to drink fluids (in some cases extra fluid is given via the child’s feeding tube). The child initially moves through 30-minute cycles with 5 minutes of encouraged fluid intake, 15 minutes of toilet sitting, and 10 minutes of dry pants checks (checked twice during the 10 minutes) while wearing regular underwear. Positive reinforcement is given for product in the toilet and for dry pants. Accidents are best managed with neutral affect, so avoid reprimanding the child for accidents.

The family will need to work with the teacher and the IEP (Individualized Education Program) team to determine when toilet training best fits into the child's educational program. If the teacher or school indicates that they have had limited experience, the family should request that a special educator within the district be identified to assist. Prior to beginning, physical therapy, occupational therapy, or speech therapy should be involved (as appropriate) to address assistive equipment and communication programming needed to accompany the toilet training program. These consultations can be obtained through the school services but, on occasion, private consultation may have to be arranged if the school lacks adequate resources.

Toilet Training in the Home

Once the child is successful at school, or in the case that initial training begins in the home, the medical home will need to arrange for consultation with a private physical or occupational therapist for in-home equipment. The medical home clinician should monitor toilet training goals at well-child exams, identify possible problems impeding progress (e.g., neurogenic bladder or constipation), and support the family in making the transition to the home environment. Be aware that nighttime continence may take longer to achieve and there is less information available on how to achieve overnight continence in children with special health care needs.

Once continence is achieved, the clinician must continue to monitor progress and may periodically arrange for physical or occupational therapy consultations.

Note: Regression is common and evaluation by the clinician may be helpful to assess for physical, behavioral, or emotional factors.

Subspecialists Collaborations

Physical or Occupational Therapy (see all Physical Therapy services providers (3) in our database or see all Occupational Therapy, Pediatric services providers (6) in our database)
Refer for assistive equipment and communication programming needed to accompany the toilet training program. These consultations can be obtained through the school services but, on occasion, private consultation may have to be arranged if the school lacks adequate resources. Once continence is achieved, consultations for additional or updated equipment, training to enhance independence as the child matures, or teaching of optimal transfer techniques for parents may be helpful.

Behavioral Programs (see all Behavioral Learning Therapy services providers (17) in our database)
Refer for behavioral desensitization if child displays fear of being in, on, or around the bathroom.

Pediatric Urology (see all Pediatric Urology services providers (1) in our database)
Refer for concerns about unaddressed medical or urological issues that may impede toilet training when a child is otherwise ready for this process.

Pediatric Gastroenterology (see all Pediatric Gastroenterology services providers (16) in our database)
Refer if a child needs additional specialized evaluation or support in managing effective stooling.

Resources

Information & Support

For Teachers:
Incontinence Issues among Students with Disabilities (Council for Exceptional Children)
A practical guide for teachers of children with special health care needs that includes terminology, schedules, and areas that need to be addressed need in toilet training; by Clarke LS, Embury DC, and Bauer A (2014).

For Professionals

Toilet Training: A Practice Guide (AAP) ( PDF Document 153 KB)
Education for clinicians about providing guidance for toilet training and recognizing parental frustration with toilet training, which increases the risk of child abuse (not focused on children with special health care needs); American Academy of Pediatrics - downloaded May 2018 from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/practicing-safety/Pages/Toilet-Training.aspx.

For Parents and Patients

Toilet Training Children with Special Needs (AAP)
An excellent resource for toilet training children with sensory disorders, behavioral disorders, autism, spina bifida, cerebral palsy, intellectual disability, and developmental disorders; American Academy of Pediatrics.

Complete Guide to Special Needs Toilet Training (One Place for Special Needs)
Extensive toilet training strategies for children with a wide variety of special health care needs including developmental and behavioral, cognitive, sensory, physical limitations, and more.

Toilet Training (healthychildren.org)
Extensive information about potty training that addresses problematic behaviors, readiness, choosing a potty, cognitive and emotional issues; from the American Academy of Pediatrics.

Bedwetting (healthychildren.org)
How to manage bedwetting and recognize signs of a medical problem; from the American Academy of Pediatrics.

Toilet Training for Children with a Disability (Continence Foundation of Australia)
How-to video for toilet training children with disabilities at home featuring an Australian occupational therapist and toilet training consultant (8½ minutes).

Patient Education

Bedwetting Brochure (AAP)
Explains the causes of nighttime bedwetting and provides techniques to help parents manage the condition until it is outgrown. Also provides signs of a possible medical problem; available for a fee from the American Academy of Pediatrics.

Toilet Training Brochure (AAP)
Details a step-by-step training program for potty training (not focused on children with special health care needs); available for a fee from the American Academy of Pediatrics.

Toilet Training Resistance: Daytime Wetting & Soiling (Contemporary Pediatrics) ( PDF Document 248 KB)
A printable handout for families with tips for helping the child to overcome hurdles in potty training.

Toilet Training your Child: The Basics (Contemporary Pediatrics) ( PDF Document 375 KB)
A printable handout about potty training using the Barton Schmitt developmental approach; includes “the bare-bottom weekend” and other helpful information (not focused on children with special health care needs).

Tools

Potty Tracking Chart (AAP) ( PDF Document 96 KB)
A simple, printable chart to count potty times each day for a week; from the American Academy of Pediatrics.

Potty Tracking Chart in Spanish (AAP) ( PDF Document 86 KB)
A simple, printable chart to count potty times each day for a week; from the American Academy of Pediatrics.

Services

For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

Foxx RM, Azrin NH.
Dry pants: a rapid method of toilet training children.
Behav Res Ther. 1973;11(4):435-42. PubMed abstract
The original and most replicated rapid toilet training program (not specific to CYSHCN). More modern practice often removes the negative reinforcement from this program.

Warzak WJ, Forcino SS, Sanberg SA, Gross AC.
Advancing Continence in Typically Developing Children: Adapting the Procedures of Foxx and Azrin for Primary Care.
J Dev Behav Pediatr. 2016;37(1):83-7. PubMed abstract
A review of adapted rapid toilet training approaches based on the original Foxx and Azrin procedure in typically developing children.

Klassen TP, Kiddoo D, Lang ME, Friesen C, Russell K, Spooner C, Vandermeer B.
The effectiveness of different methods of toilet training for bowel and bladder control.
Evid Rep Technol Assess (Full Rep). 2006(147):1-57. PubMed abstract
A review of studies examining effectiveness of primarily 2 different methods of toilet training for children with diverse health care needs. Demonstrates the effectiveness of both the Azrin and Fox model and other approaches that differ from toilet training of typically developing children.

Levato LE, Aponte CA, Wilkins J, Travis R, Aiello R, Zanibbi K, Loring WA, Butter E, Smith T, Mruzek DW.
Use of urine alarms in toilet training children with intellectual and developmental disabilities: A review.
Res Dev Disabil. 2016;53-54:232-41. PubMed abstract
A review of studies investigating the use of daytime wetting alarms to help children with intellectual and developmental disabilities.

Macias MM, Roberts KM, Saylor CF, Fussell JJ.
Toileting concerns, parenting stress, and behavior problems in children with special health care needs.
Clin Pediatr (Phila). 2006;45(5):415-22. PubMed abstract
Emphasizes the importance of medical home providers in assessing and intervening to help families with toilet training their child with special health care needs.

Kroeger K, Sorensen R.
A parent training model for toilet training children with autism.
J Intellect Disabil Res. 2010;54(6):556-67. PubMed abstract
Discusses a rapid training method for parents to use to toilet train children with autism within a few days. Articles discusses a case study of two children with autism, based on the Azrin & Foxx intensive protocol.

Wright AJ, Fletcher O, Scrutton D, Baird G.
Bladder and bowel continence in bilateral cerebral palsy: A population study.
J Pediatr Urol. 2016;12(6):383.e1-383.e8. PubMed abstract
This study describes the age of achieving day and night continence relative to the degree of motor and intellectual impairment in children with bilateral CP.

Zickler CF, Richardson V.
Achieving continence in children with neurogenic bowel and bladder.
J Pediatr Health Care. 2004;18(6):276-83. PubMed abstract
Detailed material on caring for and achieving continence for children with neurogenic bowel and bladder in a variety of settings. Written from a nursing perspective.

Authors & Reviewers

Initial Publication: February 2016; Last Update: May 2018

Current Authors and Reviewers (click on name for bio):

Authors:	Jennifer Goldman-Luthy, MD, MRP, FAAP
	Lisa Samson-Fang, MD

Authoring history

(Limited detail is available on authoring dates before 2014.)

^AAuthor; ^CAContributing Author; ^SASenior Author; ^RReviewer