Ive Tried Everything with Toilet Training, Now What?

Ive Tried Everything with Toilet Training, Now What?Strategies for supporting children, teens and adults with gaining independence in meeting their toileting needs

OTAC_CSC/DHS1Welcome!Provide overview of OTAC- current contract that this training is related too.Explain logistics: bathroom, length of training, breaks, etc.

1Parent Training Resourceswww.otac.org

OTAC_CSC/DHS2Explain online resources- recordings of webinars, register for upcoming trainings, get added to our mailing list2

Introductions

OTAC_CSC/DHS3Trainer provides introduction then asks each parent to share their name, age of the child or person they support and one thing you hope to gain out of today.

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This is a one size does not fit all approach to toiletingOTAC_CSC/DHS4This is segue slide to highlight that every child is at a different point in the process- we hope they gain ideas and strategies about next steps. Highlight that we are coming at this from a behavioral perspective. Encourage families to also share things they have tried as it may help another family.

Explain that there are many different methods and formal toilet training programs out there, which we can not successfully cover in 2 hours. So again, we are focusing on looking at this from a behavioral approach, using techniques/strategies that have been effective in our work, offer you ideas to take away and try and adapt to best meet the needs of you and your child.4

Step 1: Take a behavioral approach: AssessStep 2: Determine readiness

Step 3: Develop a routine, add supports, teach skillsStep 4: Celebrate successes, as this is a process!!

Our Approach to Toileting!OTAC_CSC/DHS5Step 1: Determine readinessStep 2: Take a behavioral approach: Assessrule out environmental and physiological factors that may impact toileting successStep 3: Develop a routine, add needed supports to the environment, teach skills i.e. communication, bladder controlStep 4: Celebrate small successes!! This is a process

5Refuses to sit on toiletDoesnt communicate need for bathroomSmears/plays with fecesRepeated flushingScreams, cries during transitionResists being cleanedGoes to bathroom in strange locationsLook below the surface.Confusion: Not sure what is expected of him/herFear of bathroom related to sensory processing Seeks ways to meet own sensory needsDiagnosis i.e. cognitive functioning, developmentCommunicationChronic medical conditionsPain associated with using the bathroomLimited fine/gross motor skillsStep 1: AssessA behavioral approach to thinking about toileting barriers (briefly explain PBS- our job is to remove barriers and put supports in place).First we need understand how these factors influence toileting success so that we can later puts supports in place and teach skills to address these factors.Explain cognitively- difficulty shifting attention (will use bathroom, but not during preferred activities), difficulty with generalization (why a child can use bathroom at home, but not school)

Discuss that a child may engage in a behavior to start an activity or initiate interaction

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This place is scary!

SandpaperToo Loud!Too Bright!Will I fall in?Too Cold!OTAC_CSC/DHS7Group discussion: sensory factors your child experiences- fears of the bathroom

*push on the sound for toilet flushing!Water splashing, clothing discomfort, temperature change, increased/decreased sensation7Always Rule out Medical!Gastro-intestinal issues i.e. ConstipationMedication side-effects (increased thirst, diarrhea, constipation)Food intolerancesDiagnostic factors (e.g. tethered cord)

Common Medical FactorsOTAC_CSC/DHS8We always want to rule out medical factors that may be impacting toileting success and consult with a physician, but it is important that we also consider medical factors in our planning process so that we can determine realistic goals.

http://www.ninds.nih.gov/disorders/tethered_cord/tethered_cord.htm8Does your child have answers to the following questions?Where am I going?What is expected of me to do in the bathroom?How long will I be in there?How will I know I am finished in the bathroom?What happens next? When do I get to finish my game?Who will help me in the bathroom??OTAC_CSC/DHS9A lot of refuses may occur because your child is confused and does not have this information.9 Activity

1. Think about what behaviors you see your child engaging in related to toileting and describe these above the surface

2. Describe what is going on below the surface that may be a factor as to why your child is engaging in the above the surface behaviors

Step 2: Determine ReadinessDoes your child?Sit and hold their body in an upright position?Show basic cooperation with undressing related to toileting?Seem to know what is expected of him/her in the bathroom?Show an interest in behaviors related to the bathroom routine i.e. hand washingAct differently when their clothing or diaper is soiled/wet?OTAC_CSC/DHS11Explain the following prior to going over the slide material (questions to consider when determining readiness, quick skill assessment):Awareness (related to elimination/defecation)- social impact for parents when children are between 2-5 years of ageDevelopmental stage (if child experiences a developmental delay it is likely they may experience a delay in toileting too)Physiological factors- can they remain dry for a period of 1-2 hrs, consistent bowel movements, dry throughout the night? Some medical conditions may contrindicate participation in toilet training. *we will discuss some medical factors- next slide

It is never to late to start or restart the process of toilet training, setting goals. In general it is recommended that toilet training should become a priority once a child is past 4 years old. It is ok if a child is not showing all of these signs of readiness in order to get started, but you both may have more success if so. These can also be a good starting point to identify areas of skill building before starting a toileting program. It is best to focus on daytime continence before moving to nighttime continence11DataIs it really needed?

OTAC_CSC/DHS12Who has time for this in a family home?

As a behavior specialist, we give you full permission to reject using any data tracking forms, unless this is a goal of yours and it is done for a short period of time, consistently.

The only reason you would really need to take data would be to help determine if there is a pattern to when your child urinates or has a bowel movement, especially if it can vary from day to day.

Let parents know that we have some simple data tracking forms they can take with them

12Habit TrainingThis method can be helpful when the person.Does not show awareness of the need to goNo change in behavior if soiled or wetOlder than six years and other techniques have not been effectiveUneven patterns of development and not meeting chronological age milestones in toileting

Making the Toilet/Void ConnectionOTAC_CSC/DHS13We can choose to hide these slides13Habit Training: StepsUse your data:select one time a day that is 5-15 minutes before your child usually goes to the bathroomIncrease regular exercise/movementEnsure your child is dry before starting- if they are already wet, just wait until the next timeKeep meal/fluid times as consistent as possibleFollow a toileting routineOnce your child successfully goes within 2-3 minutes upon sitting on the toilet for several days in a row the toilet/void connection has been established!OTAC_CSC/DHS14**Discuss reinforcement that it can be helpful but also hinder and lead to power struggles- it is important to determine what skill or behavior you are reinforcing. A child may get confused for receiving a reinforcing for voiding one day, but if unable to go the next day they may still want the reinforcer.

We can choose to hide these slides

14Step 3: Develop SupportsSet up a routine to help decrease confusionRemove barriers from the environmentPrepare the environment for success and your own sanityTeach skills needed to support independence

OTAC_CSC/DHS15Develop a RoutineWhat steps does my child already know?Attach toileting to a current routinebefore eating, leaving the house, bedtimeUse your data! Include toileting on your childs daily schedule at times when they are most likely to be successfulEatBathroomPlay

OTAC_CSC/DHS16Explain we will discuss communication supports for sharing information about their routine16Routine cont.Tip: Focus on teaching the whole routine of sequenced behaviors check schedule, enter bathroom, undress, sit, void/BM, wipe, flush, dress, wash/dry hands, exit bathroom, check schedule

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Show visual exam: Hand washing may need a whole separate set of instructions to help your child learn this routine!ples17

Fear of the bathroom (sensory factors)Difficulty transitioning away from diapers/pull-upsUrinating/defecating outside of the toiletBehaviors to meet sensory needs i.e. smearing feces, flushingResistance to using toilet paper/using too muchNeeding frequent cuesDifficult transition to/from bathroomToileting is not generalized i.e. home/schoolSome of the behaviors you might see..OTAC_CSC/DHS18Fear of the bathroom (sensory factors)Difficulty transitioning away from diapers/pull-upsUrinating/defecating outside of the toiletBehaviors to meet sensory needs i.e. smearing feces, flushingResistance to using toilet paper/using too muchNeeding frequent cuesDifficult transition to/from bathroomToileting is not generalized i.e. home/school

18Support CommunicationObject, picture, line drawing, words/signWatch for signs that your child is communicating the need to use the bathroom or to be changedgrabs at clothinggoes to a specific area of the houseincreased or decreased movements/vocalizations/distanceUse transition objects and pair with current communication methodsOTAC_CSC/DHS19

Share information about expectations that meet your childs level of representationIf a child is showing your signs- build from this skill! (give examples)

Make sure pictures cues are specific for concrete and literal thinkers: If a person sees an image of poop in the toilet they may physically place it there and not understand that it gets their by sitting on the toilet to expel waste.

Use objects to pair with current communication methods

19Social StoriesUsed to support and enhance your childs understanding of social factors related to toileting Visual way to share informationCan help to share medical information i.e. risks of refusing to change soiled diaper/clothesOTAC_CSC/DHS20See some examples!Pass out some examples20Environmental Support IdeasOTAC_CSC/DHS21

Add familiar images of bathroom signs at home which your child will see in the community!Remove distracting items- even if this is the toilet paper roll, use kleenex instead (this may be you!)Avoid flushing for sound/tactile sensitivities: are the smells (perfume, air freshner too overwhelming)The tactile part of flushing is to avoid water drops on clothing, bare bottom; use stool sample catcher to avoid splashing if neededOffer alternative water play opportunitiesControl temperature: adapt sink if necessary, cover lever for excessive flushingIncrease stability while sitting-Provide a stool or smaller/larger commode or seat, bars on side of toilet, sit with toilet covered at firstExplain environmental modifications to support independence: sensors to eliminate turning on/off- flushing, sensors for sink to prevent overflowPrivacy- this may be why a child is going to the bathroom in a dark closet: remove light, people, able to squat etc.

21Stress ReducersEasy to access clean-up kits for home and the vehicle (always keep a change of clothes in the car)Provide universal precaution kits for caregiversInstall a bidet attachment to the toiletFlushable wipesAdaptive clothingWaterproof mattresses or mattress padsOverstock on towels and washcloths so you dont run out in a touch situationWaterproof cases for devices if entertainment is needed for the longer sits

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OTAC_CSC/DHSWhere do I stand?How much do I use?This person didnt know where to stand when he went to bathroom. The mats on the floor told him generally where to stand Initially, foot prints were tried, but the person wanted his feet to fit exactly in the foot print, and it made him more frustrated than not knowing where to stand23DesensitizationAllow your child to sit on the toilet with their diaper on- slowly overtime cut away the diaperKeep lid closed when practicing to sit downHave your child touch and hold the toilet paper or wipe prior to wiping their bottomHave your child stand away from toilet when flushing, say ready, set, flushIf your child is afraid of the bathroom-focus on being in the environment without placing any toileting demands

OTAC_CSC/DHS24Fear of bathroom- pair it first with preferred items.24Skill DevelopmentHow do I increase the length of time my child will sit on the toilet?Routine: Count to a specific number, sing or use a visual timer to show how long to sitKeep expectations for sitting short at first Place a small table outside over the childs lap with toys and other items to keep him/her entertainedPlace a weighted item on your childs lap i.e. rice/bean filled sock, lap pad (sensory)

OTAC_CSC/DHS25Difficulty sitting-*reinforce small steps

25Teaching StrategiesTeach bowel/bladder control: Show how to gently apply physical pressure on lower abdomen to help empty bladderPushing- clench fists, feet up on stool, hunch overUse a doll to model toileting behaviors if child is unable to observe the process of othersTake turns sitting on toilet, use visualsUse hand-over-hand to assist your child with dressing and wipingUse chaining to support independence within the toileting routine

OTAC_CSC/DHS26Hand over hand: helps to teach your child the routine and muscle memory of each actionPre-teaching: cuespractice wearing underwear for short periods of time

26Things to AvoidPhysically restrict a childs movement while in the bathroom i.e. holding them to sit longer on the toiletResponding emotionally if an accident occursLoud cheering/applause once the child begins to void Lecturing, scolding or shameful statements i.e. only babies where diapersTrying to push a child to overcome a fear or discount the fearAvoid excessive increase/decrease of fluid intakeAvoid rushing steps in the routine!OTAC_CSC/DHS27Presenter will explain what to do instead for each of these if neededAvoid cheering: This may create a shock response and impact the persons ability to fully empty their bladder

27Signs that toilet training is a success!Your child indicates a need to use the bathroom Accesses the bathroom on their own without relying on cues from othersUses the bathroom in different settingsYou notice a decrease in the amount of diapers/pull-ups being usedIncreasing skills- no matter how big/small or how long it takes accomplish it!

OTAC_CSC/DHS28Remind parents the importance of documenting even small sucesses 28 Activity

Look at your list of possible underlying factors and tips you have learned today. Determine 2 or 3 action steps and support ideas.

Step 4: Celebrate successes!! OTAC_CSC/DHS30

References30ReferencesWheeler Maria, M.ED; Toilet Training for Individuals with Autism or other Developmental Issues; 2007TEACCH-Applying Structured Teaching Principals to Toilet Training; 2005Heffner Gary J.; Toilet Training- Autism printable article #25; 5/9/2002http://www.ninds.nih.gov/disorders/tethered_cord/tethered_cord.htmOTAC_CSC/DHS31Remind them to fill out evaluations-31