This post has been written by June Rogers, Children’s Specialist Nurse at Bladder & Bowel UK. June talks about toilet training children with additional needs. Becoming toilet trained is a milestone all parents strive for with their child, particularly if that child has additional needs. For some parents, this seems an unachievable goal. However, experience has shown us that for the majority of children this clearly is not the case.

I always explain to parents that becoming toilet trained is like climbing a ladder

At the bottom of the ladder is the fully dependent nappy-wearing infant. And at the top of the ladder is the fully independent, bottom wiping, toilet flushing, hand washing, toilet trained child. What we aim to do during the whole toilet training process is to enable the child to get as high up the ladder as we can. Some children we only get half way up. So, although they are clean and dry and wearing normal underwear, they will always need some help and support regarding toileting.

However children always surprise us and, as we do not have a magic wand, the fact that some of these children reach far higher up the ladder than we would ever have thought possible, means that they had that unrecognised potential to do so. We clearly have a duty of care to support families to enable every child to reach their full potential.

Many parents say they have not started toilet training their child as they have been told they were not ’ready’. I have been toilet training children for nearly 30 years and never in that time has a child put their hand up and told me they were ‘ready’ to be toilet trained!

Becoming toilet trained is a developmental skill, similar to learning to walk and talk, yet we seem to treat delayed toilet training differently. For example if we are aware of a child who has speech and language delay then we would automatically refer them on to a speech and language therapist. Similarly if we had a child who was struggling to learn to walk then we would refer them for an assessment, to try and identify the underlying cause, with a referral on to a physiotherapist if necessary. We definitely would not say that as the child shows no interest in walking we would wait until he was ’ready’ to walk and only then we would refer them on. Neither would we ignore a child with delayed speech saying that when they showed an interest in talking only then would we do anything about it.

So why is it that, in the vast majority of cases, when a child is clearly struggling to become toilet trained at an appropriate age, parents are told that the child is ‘not ready’ and nothing is done about it?

Becoming toilet trained is the interaction of two processes. The first is physical maturity of the bladder and bowel. This improves with toilet training, but develops in most children from about two years old. The second is social awareness and motivation of the child. We can therefore clearly see why some children with additional needs may struggle with the toilet training process; they often have no social awareness and are not at all motivated to use the toilet, because their nappies keep them warm, feeling dry and comfortable!

That said children with additional needs are just as likely as their typically developing peers, if not more so in some cases, to have an underlying problem with their bladder and bowel. This may be the cause of the delay in them achieving bladder and bowel control. For that reason all children, who are struggling or delayed with toilet training (not toilet trained by their third birthday) should undergo a comprehensive assessment to exclude and address any underlying problems such as constipation.

All activities of daily living, such as washing your face and cleaning your teeth, have to be taught in an appropriate timely way. We don’t, for example, wait until a child has a full set of milk teeth at age 3 before we present them with a tooth brush and a tube of tooth paste, without them ever seeing them before, and expect them to independently start brushing their teeth. We introduce the toothbrush when their teeth start to come through and also spend time showing them what to do. So, by the time they are 3 years old most toddlers can make a decent attempt of tooth brushing.

Why then do we suddenly present a toddler with a potty, sit them on and expect them to happily sit there and produces a wee or a poo when they have really no idea what it is all about!

The potty should be introduced at around six months of age. After, weaning the poos usually become more predictable and most children have developed a good sitting balance by then. By gradually introducing the potty at set times during the day, it quickly becomes part of the child’s daily routine.

Along the way, more by good luck than expectation, you may be able to ‘catch’ a wee or a poo. This should be responded to with lots of praise so that the child understands that this is a good thing to do!

Once a routine has been established, the child has some awareness and understanding regarding wees and poos and of what is expected and there are no major disruptions, such as starting nursery, moving house etc, then that is the time to remove the nappy and put a formal toilet training programme in place. This ideally should be when they are two to two and a half and no later than about age 3 years.

Parents should ask for help, sooner rather than later, if things are not going according to plan. The formal toilet training process should only take a couple of weeks at the very most. All the background work, such as potty/toilet sitting, awareness of wee and poos etc, would have been done previously.

More information about toilet training children with additional needs

For further information and advice regarding all aspects of toilet training look at the Bladder & Bowel UK website resources page or contact us via our confidential helpline 0161 214 4591 or on email bbuk@disabledliving.co.uk.