Toilet Training
Toilet training can be a confronting experience for both the parents and child. It is a time-consuming process, which requires both the parent and child to be “ready”.
There have been conflicting statements between parents and research on the “window of opportunity” for Toilet training. However, it is important to understand the physiological, emotional and pragmatic circumstances that are necessary to truly be ready for toilet training.
When will my child be ready?
It is important to know that there are important physiological milestones that assist in a child’s readiness in toilet training.
1. Physical skills
- Consistency of bowel and bladder movements.
- Control of sphincters (muscles responsible for controlling the evacuation process).
- Physical ability to sit upright on toilet or potty and not fall off.
- Ability to undress and dress as needed (including managing buttons, zips and knowing how to plan and sequence dressing and undressing).
As adults, we know we need to go to the bathroom through the sensations we feel from our bladder or bowels stimulating the signals in our brain. These sensations are activated from the stretch of our bladder or bowels walls (i.e. the more urine in your bladder, the larger the stretch of your bladder walls, the larger the sensation to stimulate the brain). As children, we are still learning and understanding what the different sensations and signals from our body mean. Young children do not completely understand the signals being sent to the brain and have no conscious control of their bladder or bowels. Rather than controlling their own movements, a reflex will naturally void their bladder or bowels when they are at full capacity.
As children get older the size of their bladder begins to grow meaning it will take longer for them to fill their bladder enough to void therefore their nappies remain dry longer. By this time, children typically start understanding the difference between feeling wet or dry and this is a good time to begin toilet training. For this reason, it can be beneficial for some children to wear underwear over disposable nappies because it will be easier to feel the difference. Children’s awareness of being soiled develops before their awareness of needing to go so do not feel discouraged if your child has multiple accidents as they begin transitioning into underwear. It is also beneficial at this time to begin involving the child in changing their nappy or underwear and cleaning themselves up when they have soiled themselves, introducing their independence and responsibility in toileting.
2. Sensory Processing
- Awareness of soiled and wet nappy (i.e. body awareness, tactile discrimination).
- Awareness of need to toilet (with enough time to get there).
- Ability to cope with the sensory environment of toileting (noises of flushing toilet and taps at the sink, echoing sounds of tiles, hand dryers, bodily smells, smell of air fresheners).
- Attention to task and ability to sit still long enough to toilet (more than 5 mins without an adult needing to help them stay sitting).
- internal (i.e. reading the body’s signals and managing the feelings of toileting).
- external (including toilet seat, toilet paper, smell, noise, clothing on skin).
The next physiological milestone is building their conscious control of their bladder and bowels. When children start realising their need to go, there will initially be a mad rush to the closest toilet. This will come with much trial and error. In order to hold their bladder from voiding, they will have to consciously control the sphincter (i.e. gate between bladder and urethra). Remember that children only start sensing their need to void when their bladder is completely full, and their muscle may not be strong enough to hold their entire bladder for long periods of time. Furthermore, even if the child can hold their bladder by activating this muscle (the sphincter), the process of relaxing this muscle is also a difficult task. Therefore, it can take a while for the child to void their bladder after your rush to the toilet because they claimed that they cannot hold on. As they gradually develop control of their sphincter and the hold and release of their bladder, they will be able to hold for longer and be more consistent. This is generally, when self-initiation begins to develop.
3. Concept understanding
- Comprehension of the sequential steps of toileting and dressing (e.g. pull pants down before sitting on the toilet).
- Attempts to remove clothing in readiness for toileting.
- Attempts to request or communicate needs to others (e.g. I need to go to the toilet).
- Awareness of the routine or sequence of toileting.
- Awareness of the task that is required of them when in the bathroom.
Once a child has mastered these few milestones their ability to void from a partially full bladder and the ability to start and stop their flow begins. The control over their bladder increases and lastly the final goal is to have night time control. Keeping in mind that night time control occurs with time and patience.
Developmental and health related challenges with toilet training
- Medications may have an influence on bladder and bowel movements
- Food protein allergies and intolerances, can cause diarrhea, constipation or both
- Maturation of the nervous system may occur later
- Children with down syndrome may have slower bowl movements
- Children with Cerebral palsy may have a neuropathway impairment which reduces their ability to feel sensations of the bowel of bladder
- Delay in motor control impacts mobility, balance, coordination, and motor planning required to sitting position
- Delay in language impacts comprehension of instructions and ability to express needs
- Delay in cognition or cognitive impairment impacts understanding of purpose of toilet, social rules of toileting, or attention require to go to the toilet
General educational activities for toilet training
- Storybooks and apps for toilet routine
Unpack the different steps necessary to the toilet routine starting from feeling the sensation to needing to go to the point of washing their hands. Make the story fun and interactive, ask their opinion and unpack their understanding and/or fears towards the routine. Make a visual story book together.
- Books, pictures, videos and apps about how the body works
Provide your child with opportunity to understand how their body works (i.e. when we eat or drink food, out body takes all the good stuff and we let all the useless stuff go to the bottom of the toilet).
- Draw, describe or talk about internal sensations of the body
Draw around the child and identify where you feel certain sensations (i.e. I feel grumbly in my tummy when I am feeling hungry or I feel full down here when I need to go to the toilet). Ask them where they feel certain sensations first. Correct them if they struggle with the appropriate positioning of some sensations and reward them if they guess correctly. First try hungry, thirsty then move on to toilet related sensations.
- Knowing Wet and Dry
When your child is undressed and ready for a shower/bath take a cloth and have it wet on one half and dry on the other. Have your child close their eyes or stand facing away from you, take the cloth and dap it on your child’s upper leg, bottom, inner thigh with either the dry or wet side and ask them, “Dry or wet?” and see if they are able to identify the different sensation over the area that will generally feel wet or dry when they are toileting.
(‘Building Blocks of Toileting’ sourced from Kid Sense)
Written by our Occupational Therapist Anna Blackmore
If you feel you need more information or assistance please don’t hesitate to book in with one of our Occupational Therapists on 07) 5636 9458.
"Alone we can do so little; together we can do so much"
– Helen Keller
