Rhode Island Medical Home Portal - Toilet Training for CYSHCN

Primary care clinicians frequently address toilet training questions in the general pediatric population, and there are excellent and abundant materials to help address questions about this topic. However, for children with physical, intellectual, or sensory delays or disabilities, answering questions about potty training is more challenging, and most clinicians have not received training specifically in providing anticipatory guidance about this topic for children with special health care needs. The following provides background information for clinicians to help determine when a child with special health care needs may be ready to train, and about toilet training at school and in the 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. It is important to touch on this issue early, when the child is 2 to 3 years old, and to indicate to the family that, while achieving continence might take time, it is likely something their child can accomplish. Also, find out when parents desire to focus on this goal. Basic requirements to determine when the child is ready include:

Diapers are dry for at least 30-minute periods.
Recognition of wetting and soiling (not necessarily discomfort) is occurring. Sometimes the child has to be changed into regular underwear instead of absorbent diapers or pull-ups for a few days to assess this.
Age is > 4 1/2 years (usually).
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 ruled out.

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.

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.

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 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 (PT), occupational therapy (OT), or speech therapy (ST) 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 rare 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.

Subspecialists Collaborations

Physical or Occupational Therapy
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 (see all Physical Therapy services providers (6) in our database or COAST Clinic at Bradley Hospital, (401-432-1119); See also Services below).

Behavioral Programs
Refer for behavioral desensitization if child displays fear of being in, on, or around the bathroom (Behavioral Programs service provider listed under Services below).

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

Pediatric Gastroenterology
Refer if a child needs additional specialized evaluation or support in managing effective stooling. (Children's Neurodevelopment Center, (401-444-5685); See also Services below).

Resources

Information & Support

For Professionals

Toilet Training: Practice Guide (AAP)
Educational module for clinicians on understanding and providing guidance for toilet training in children (not focused on children with special health care needs), in recognition that parental frustration about toilet training increases the risk of child abuse; American Academy of Pediatrics.

For Parents and Patients

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

Guide to Special Needs Toilet Training
Extensive resource listing for toilet training strategies for children with a wide variety of special health care needs; One Place for Special Needs.

Services

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

Helpful Articles

Azrin NH, Sneed TJ, Foxx RM.
Dry bed: a rapid method of eliminating bedwetting (enuresis) of the retarded.
Behav Res Ther. 1973;11(4):427-34. PubMed abstract
A very dated publication, but the most replicated timed sitting program with negative reinforcement removed.

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.

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.

Authors

Author:

Lisa Samson-Fang, MD - 10/2008

Reviewing Author:

Jennifer Goldman-Luthy, MD, MRP, FAAP - 3/2016

Content Last Updated:

3/2016