Toileting for additional needs
- Peeing, pooing and toileting
This page has a series of online learning sessions that have been specifically created to support families and professionals learn about continence management. Please take your time to watch through each session.
Objectives of the session
- Know when to start toilet training and what things to consider
- Have an understanding of common physical problems for all children
- Have an understanding of physical disabilities and behavioural problems
- Know where to go for help and support if needed
Why toilet train and readiness
Toilet training is important for the dignity and comfort of the child and carers, providing a sense of achievement and good bladder and bowel habits. Becoming toilet trained involves the development of the bladder and social and cultural awareness. Some children may never show readiness, but this does not mean they aren't able to be dry.
Hello, my name is Gemma Farrand, and I'm a Special Needs School Nurse for CCS. This workshop where we will cover toilet training and continence issues for children and young people with additional needs. What we will cover today. When to start toilet training and things to consider, common physical problems for all children, physical disability, behavioural problems, sensory sensitivities, social inabilities and where to go for help and support if required.
Very few children are unable to develop some degree of continence. This is the same for all children with additional needs. For children with mild to moderate learning disabilities, the Eric website recommends to start by treating them as you would any other child. So why toilet train? For the dignity and comfort of the child in care and the carers; so they can feel the same as their friends and siblings, it is worth mentioning here that some autistic children may not be motivated like their peers would to wear pants and use a toilet; is a sense of achievement, most children like praise and the feeling of success; it provides good bladder and bowel habits.
Whatever level of continence your child may be able to achieve, promoting a healthy bladder and bowel is so important. Disabled changing facilities are not always available, which can make being out and about difficult at times. Continuous use of nappies can cause sore skin rashes and can leave the child and more risk of urine infections. Success levels for toilet training can depends on several things. Giving yourself plenty of time to achieve what you set out to achieve; your child may always need some support with toileting, but any amount of continence is better than none at all.
Making sure there is a consistent approach in all areas of your child's life, such as schools, nurseries and with carers and with all of the family members. Using a toilet in plan that goes with your child wherever they go, can helps, so that consistency can be reached in all areas, and the expectations of everyone involved are understood. Staying patient, it may not be a quick process.
Children with autism may take longer than other children to learn a new skill, which is exactly what toilet training is. Using relevant rewards, praise and positivity. Praise the achievable tasks such as sitting on the toilet, washing hands and helping getting dressed and undressed, rather than the actual pooing and weeing. How can we prepare children and young people for toilet training? If you don't already, start by changing your child in the bathroom standing up, this can be the first link for them that weeing, and pooing is managed in the bathroom. Lots of talking about going to the toilet, demonstrations, such as teddies having wee. And decide what language you're going to use with your child. Will you call it wee or poo? Or do you have a different name for the toilet? Encourage your child to help with undressing, wiping, flushing and washing and drying hands. Do this as part of their daily routine.
When accidents happen, try not to make a big fuss. Start sitting them on the toilet. You may have to start off sitting them on the toilet fully clothed, just to get them used to it. Readiness. Becoming toilet trained is the combination of two processes: development of the bladder and the social and cultural awareness. Some children won't ever show readiness, but that doesn't mean they aren't able to be dry. Many children with autism and developmental delays will not show the usual signs, but are able to toilet train with a calm, consistent and sustained approach.
So, some factors to consider are: is your child going at least an hour and a half in between wet nappies? Is your child passing soft stools between three times a day and four times a week? Can your child sit safely and comfortably on the potty or toilet for at least a minute? If the answer is yes to all of those questions, it's time to start thinking about toilet training. Some of the aspects to think about before starting are: Does your child know when they need to go to the toilet or have been to the toilet? do they know how to communicate this with you? can they pull their own pants down or wash their hands on their own? are they able to respond when asked to do something? and are they sensitive to anything? By thinking about your child's abilities you can consider what you may need to put in place before starting any toilet training. Preparation is key, and simple strategies can be really helpful towards successful outcomes.
So, some difficulties you may see along the way. A basic toilet training issue such as accidents, not getting to the toilet in time and not wanting to sit on the toilet; withholding poo due to previous trauma or toilet anxieties; soiling or smearing poo on surfaces or themselves; bed wetting and; day wetting; going to the toilet in inappropriate places; anxieties around using different toilets; and only being toilet trained at home or at school.
Day time wetting
Day time wetting is caused by a natural delay in the maturing process. This means the bladder continues to work like an infants, emptying small amounts and regularly. It is common in children with and without special needs. It can be hereditary or caused by constipation or a urinary tract infection.
Day wetting. One in seven children aged four and a half are wet in the day and one in 20 children aged nine and a half suffer from daytime wetting. It can be caused by a natural delay in the maturing process, so the bladder continues to work like an infant's, emptying small amounts and regularly. It's common in children with and without special needs. It can be hereditary, so if one parent was late to become continent, there's a 50% chance their child will also be late. And if both were late and achieve incontinence, then there's a 95% chance. It can also be caused by underlying reasons such as constipation and urinary tract infections, so it can be worth getting checked by your GP.
Constipation, as you can see from the picture, can cause daytime wetting due to the build-up of poo in the bowel pressing on the bladder, causing wee to leak out. So, it's crucial to find out as soon as possible and treat before starting a toileting program. Drinking six to eight glasses of water-based drinks a day and weeing at regular intervals can help to regulate the bladder.
Daytime wetting can also be caused by an overactive or unstable bladder. This can be diagnosed through a completion of a bladder and bowel assessment chart. This means keeping a close eye on your child's output over a few days. Also, by completing a bladder and bowel assessment chart, you will be able to see roughly when your child wee and poo and spot anything that needs attention.
What is an overactive or unstable bladder? A normal bladder relaxes, letting all the urine in as we drink. Once the bladder fills up, it sends messages to the brain to tell us to go to the toilet where we then empty our bladder. An overactive or unstable bladder, instead of letting the bladder fill, it gets twitchy, which means instead of the bladder relaxing and filling before empties, it squeezes intermittently and let’s wee out prematurely.
If your child has an overactive bladder, they may be weeing lots of smaller amounts, or they may not give you much warning when they need to wee. It's very common and effects lots of children over five years. The first treatment for an overactive bladder is bladder exercises, which consists of regular drinking and toileting, which then enables the bladder to stretch and grow. If this isn't successful, medication can be used to help relax the bladder.
Night time wetting
Causes of bedwetting include constipation, family history, not waking up or having an overactive bladder. Encouraging your child to drink at least 6 water based drinks per day and going to the toilet at regular intervals can help.
Bed wetting or nocturnal enuresis is very common and affects a lot of children over five. For example, in a class of 30, 4-5 children are likely to be affected by bedwetting. What can cause bedwetting? As we said in the last slide, when your bladder is full, it sends messages to the brain to empty. For some children, this message isn't loud or clear enough when they are asleep. So, as a result, they don't wake up and their bed ends up wet.
Other reasons it might happen are: Constipation. Like with daytime wetting, if the bowel is full of poo, it can press on the bladder, causing leakage overnight, which then makes it more difficult to hold onto your wee; Family history. If either parent had a problem with bedwetting, then there is a chance their child may also; Drinking large quantities of a specific drink. Such as blackcurrant, caffeinated or fizzy drinks. These can irritate the bladder; Overactive bladder. As we discussed in the last slide, the bladder twitches before it’s full, emptying in the bladder prematurely. Or it may be that the bladder isn't big enough to hold onto the fluids overnight. It could also be a lack of vasopressin, which is the chemical messenger that tells your kidneys to shut down and produce less urine overnight.
Treatments for bedwetting include: As with the treatments for daytime wetting, drinking at least six water based drinks and go into the toilet at regular intervals is so important to get your bladder into good habits; going for a wee before bedtime and again lasting before you go to sleep and restricting fluid intake after dinner can also help. If the cause is constipation, once treated, eat lots of fruit and vegetables and make sure you are doing at least three poos a week; Enuresis alarm. So, this is an alarm that wakes the child when they start to wet overnight. The sensor, that's attached to the alarm, can either sit under the sheet or sit in the child’s underwear. The alarm works by helping the brain recognize the signals when the bladder is full; Medications. So, Desmopressin is the name of the medication that works the same as Vasopressin, which, as we said earlier, is the chemical messenger to the brain that tells the kidneys to produce less urine overnight.
Constipation, soiling and smearing
Constipation is the most common bowel problem in children. It is the inability to do a poo regularly or completely empty the bowel. Smearing is when your child spreads poo on walls, themselves or their clothes. One reason for smearing is if the bowel is full then soiling may occur due to overflow or poo sat in the bottom.
Constipation is the most common bowel problem in children. It's the inability to do a poo regularly or to completely empty the bowel. Children should be opening their bowels between three to four times a week less frequent than this, and the poo becomes dry and harder to pass. If your child experiences pain and discomfort when having a poo, this may be a sign of constipation. Poo should be soft, easy to pass and look like a sausage, which is number four on the Bristol stool chart that you can see on the slide. Going more than three times a day isn't right, either. This could be something called overflow, where the new poo is bypassing the old poo, and it comes out as liquid, which is number seven. Children can get large formations of poo in the bowel, which stretch the bowel and then press on the bladder, causing urine incontinence, which is why it's so important to know whether your child is constipated before you start a toilet training program.
Blockages can occur when constipated, which requires treatments to disimpact the bowel. And constipation is a common reason for smearing and soil in which you talk about more in depth in a couple of slides. So, management of constipation is really important to drink at least six to eight drinks of water-based fluids a day. Having a regular diet containing lots of fruit, vegetables and fibre. Exercise, if possible, this helps keep everything moving along, including your bowels. Getting into good bowel habits, such as sitting on the toilet 20 to 30 minutes after a meal and before bed. Your child's feet need to be firmly supported with knees above their hip, back straight and leaning slightly forward, as you can see in the picture. They should sit for five to ten minutes using distraction techniques, if need be, such as the iPad, reading, colouring, toys, whatever it takes. Some techniques you can use to assist with opening the bowels are to roll back and forth on the toilet, to do tummy massaging circles clockwise, and bubble blowing and coughing are also really useful to get the tummy muscles pushing down. Medications play a big part in treating constipation and your GP will be able to prescribe the right medication for your child.
Smearing. So, smearing can be described as spreading poo on walls, themselves, clothes. Anyway, it shouldn't be basically. Why does it happen? If the bowel is full, you can get soiling in the underwear from either overflow or poo that sat in the bottom. For some children, it may be a way of communicating that they have done a poo and it feels uncomfortable. They may be curious about what they can feel and smell in their pants or nappy. Some children enjoy the feeling of it on their hands, and they find the smell and texture stimulating. And some children just enjoy what happens afterwards. They get to have a nice warm shower or bath, which they may see as a reward. What you can do? So, first of all, it's important to think about why it is happening in the first place. Treat the constipation if this is the cause. Try and deal with it calmly. Experiencing a big reaction the first time it happens can unintentionally reinforce the behaviour. Provide alternative sensory stimulation such as Play-Doh, cornflour gloop or strong-smelling perfume on a handkerchief, visual support and social stories, which we will talk about more later and making sure they are wiping their bottom correctly.
Behaviour and sensory sensitivities
Behavioural issues that are seen include withholding poo/wee, anxieties or fears around the toilet, only pooing in a nappy or only using a toilet at home. Sensory sensitivities involve a child being under or over sensitive to sight, smell, sound, touch/feel and balance/body awareness. If your child has sensory sensitivities there are lots of things you can do to help.
So, some behaviours we may see: withholding poo and wee. This is very common in children, it can start because of a traumatic experience, such as pain when passing in poo or an anal fissure, which is a small tear in the anus caused by passing a large poo. Working with your child around this, taking slow steps, positivity, raise and rewards will often work. Anxiety and fears around the toilet is also very common, such as fear of the flush or fear of falling into the toilet. For this, you could get a smaller toilet seat to go on top of the toilet. Let your child help pick one. If it's to flush your child's afraid of, you could start by not flushing and gradually build up their tolerance of the flush. It's crucial to find out what those anxieties are and deal with them accordingly. Some children will only poo in a nappy. With this, it's important to find out why they won't sit on the toilet and do some work with them around that, rather than refusing to let them poo in the nappy. This will just lead them to withhold their poo, which then leads to constipation and other issues.
Only using a toilet at home. So, using a consistent toileting routine when using all toilets will help with this. You can reinforce this with a visual schedule, which we will discuss shortly. Familiarize your child by showing them where toilets are in new places and practice going inside. Bring in personal items out with you, such as toilet seats and toys, and preparing them before going to a different toilet. A radar key, sometimes called an NKS key, opens more than 10,000 locked disabled toilets in the UK. It may be worth considering getting one of these if your child has difficult behaviour in public toilets.
Sensory Sensitivities. So, 70% to 90% of children on the autistic spectrum have sensory differences. They may be hyper, which is oversensitive or hypo, under sensitive to sight, smell, sound, touch, feel and body balance awareness. We will now look at these senses and see how we could deal with the sensitivities.
Sight. If it's the light your child doesn't like, replacement strips or fluorescent lighting with low wattage, coloured bulbs or night lights can help. If it's the mirrors that are the issue, cover it up, remembering any reflective tiles also. Make the bathroom child-friendly with posters, pictures and toys. One mum turned her bathroom into a spaceship to get her son using the toilet. It's also worth thinking about whether they like the door open or closed.
Touch. Is the bathroom to warm or cold. Let your child choose their own toilet paper, whether it's patterned or has characters on it, is soft or wet toilet tissue. You can get dispensers if they overuse it. Use a padded, heated toilet seat. If it's splashing, they're sensitive to, put toilet roll in the toilet. Use a soft, non-slip rug on the floor. Have a box of favourite sensory toys, books and things that your child likes. If your child does not like feeling wet, it may be that you can use this to provide some motivation for your child to toilet train. Nappies are very efficient at absorbing wee these days, so you could put your child in pants underneath the nappy so they feel wet when they wee. If it's sound your child is sensitive to, not flushing the toilet when your child is in the bathroom or giving them warnings before flushing the toilet, distracting your child with music or other sounds that they like, you could try using ear defenders or earphones. De-sensitisation. So, gradually building up your child's tolerance to the sounds that they dislike.
Smells. So, ensuring that the bathroom has good ventilation and air circulation to reduce smells, replacing smells they dislike with something else they like, such as an air freshener. Think about other smells in the bathroom they may not like, such as cleaning products.
Balance and body awareness. If your child feels unbalanced when sitting on the toilet, use grab rails so your child can hold on to them whilst on the toilet, non-slip mats on the floor to prevent them from slipping, a weighted best or lap pad may help keep the child sitting on the toilet for longer, portable toilet seats to make the hole smaller or just more comfortable. Try and enclose the toilet area if afraid of open spaces such as shutting the door.
Social communication and understanding. So, some children with learning disabilities, especially those with autism, can struggle with communicating what they want, but also understanding what is being asked of them. They may not recognize nonverbal communication, such as facial expressions and body language, or be able to express what they need. This means that they may not understand the words used for toileting. So, they may not know what is expected of them. They may take language literally, for example, putting the whole toilet roll in the toilet rather than just the used part. They may be less likely to communicate the need to go to the toilet. Using visual aids and social stories can help overcome these.
Social Interaction. Some children may not understand the expected behaviours and may have difficulties with relationships and social situations. Because of this, they may not be interested in being the same as their friends or siblings, wearing big boy/girl pants and using the toilet. They may not learn by copying other people, and they may not want to please you. They may not be concerned about being wet or soiled. Using rewards to motivate your child can help with this. It should be something small that your child is interested in, and that can be provided as soon as they have done what has been asked.
Imagination. Children with autism may not use imaginary or social play. They can be rigid in their thinking and struggle to understand what comes next, which may mean they don't adapt very well to changes in routine. This means that they may assume that you know what they need help with and not realize that they need to tell you. They may have difficulties with changing their routine, and they may struggle to transfer knowledge, which is why some children may only be toilet trained at home and vice versa. They may not realize the impact that certain behaviours have on other people, and they may also develop fears and anxieties. Making changes slowly and gradually with the support of picture cues or social stories may help them to feel safe and accept the changes better.
Visual Aids. Many children with autism are visual learners, they understand and learn more easily when pictures are used. Visual aids can be used before toilet training has started on a daily basis to help prepare them for what's to come. Familiar tools like this can help to manage anxieties and prevent difficult behaviours. They should be used consistently at home and school to prevent confusion. They should be child specific as all children are different and require varying amounts of support and have different routines. On the example, you can say it may be that your child doesn't like the flush, so you may choose to remove that picture altogether or move it to the last part of the story. There's also quite a few pictures in this example, and this may be too much for some children. You can use drawings, pictures or photographs, whatever your child will respond better to. Using pictures to communicate needing to go to the toilet may also prevent accidents.
Before you start toilet training
Before you start toilet training think about if everyone is ready and if it's the right time for your child and family. It helps to involve your child and get to know their routine. Take a holistic approach and consider everything going on for your child. Make sure everyone is working together with a consistent approach.
Before you start toilet training. Think about is everyone ready to start? Is it the right time for the child and family? For example, you haven't just had a new baby or moved house. These are big changes in a child's life, so adding another big change, such as toilet training may be too much for them to take on board at that time. Involve your child. Talk to them about it. Read them books. Get to know your child's routine, doing the bladder and bowel assessment that we spoke about earlier can help. Think about what behaviours you are seeing in your child. Why do you think the child is behaving this way, and how do you help reduce or replace these behaviours? Take a holistic approach, consider everything else going on with your child and make sure everyone is working together with a consistent approach. Planning a toilet training program. Identify a pattern to your child's weeing and pooing. If you know when your child poos every day, then make sure your child sits on the toilet around the same time. If not, then sit your child on the toilet 20 to 30 minutes after meals and before bed. For wees, start by sitting your child on the toilet regularly. Put a timetable together for everyone to use to maintain consistency. Choose clothes that are easy to pull up and down, and easy to wash and dry, as there will be lots of accidents.
How will you communicate toilet time with your child? Using visual aids objects of reference? What words will you use for wee and poo. Organised toys and other distraction methods for sitting on the toilet. Try and keep these just for the toilet. Decide on a reward system. You should be rewarding the achievable goals, such as washing your hands, sitting on the toilet and helping to get dressed. Rewards need to be instant, so they associate it with what they have just accomplished.
How can we help? We are here to help you and support you if you are struggling with toilet training. We can help you with bladder and bowel assessments if required. This will give us the information we need to put a toilet plan together for you and identify any issues that need addressing. We can refer on to other specialties, such as Occupational Therapists. We can give telephone advice. We can signpost to support websites and information. For some children, toilet training is unlikely to be possible. And in this case, it's our priority to find the right product that will keep that child most comfortable. We will then provide a product assessment and referral to the continence's product service.
Who to contact. Our contact details at the top if you need to get in contact with us for further advice and support. Bladder and Bowel UK, and ERIC are fantastic charities that have websites that, as professionals, we use to help guide us in our support and knowledge and advice. But the information is there for you as families also. So, if you need further information, please visit these websites. Fledglings are a non-profit shop that helps families with disabled children by supplying products and equipment that help with everyday challenges. They have lots of toileting aids and equipment.
Thank you for watching this presentation on continence issues for children with additional needs. Remember, just because your child has a disability doesn't mean they shouldn't be given the opportunity to achieve continence. There aren't any quick fixes. Toilet training can be hard and extremely time consuming, but ultimately can be a life changing skill for that child and family. Thank you.
Last reviewed: 1 November, 2023