Potty Training for Children with Challenges

• Christy Moran, OTR• Tasha Heinze, SI• Rachel Harvey, MOM• Chris Asbeck, MOM

OBJECTIVES

• Participants will understand general potty training

• Participants will understand and be able to adapt potty training techniques to meet individual situations and challenges

What’s the Big Deal?1. Recognize the need to go2. Wait to eliminate3. Enter the bathroom4. Pull down clothing5. Sit on the toilet6. Eliminate in the toilet7. Use the toilet paper correctly8. Pull clothing back up9. Flush the toilet10. Wash hands with soap11. Dry hands

Where to Start

• Start teaching steps 5 and 6– Sit on the toilet and eliminate in the toilet

• You will do steps 1-4 for your child– Recognize the need, wait, enter the bathroom and

pull down the clothing• Help your child do steps 7-11

– Toilet paper, flush, pull clothes up, wash and dry hands

Is Your Child Ready?

Follow simple directions?

Sit in a chair for 5 minutes?

Dry for 1 ½ hours?

Are You Ready?

Time

Patience

Consistency

Why Start with BMs?

• BM’s are consistent • BM’s are infrequent (once or twice a day)• Diapers are continued during BM training• Less time during the day is needed for BM

training for child and parent

Let’s GO!• Determine your child’s pattern

– Keep a record for 2 weeks– Do not change your routine during this time– Record from the time your child wakes up, every

hour if the diaper is wet, soiled, or dry– Use a chart that you only have to check wherever

you normally change diapers– This is to establish your child’s pattern of

elimination and make your job easier

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

7:00

8:00

9:00

10:00

11:00

12:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

7:00 U U D U D U U

8:00 D D UBM D D D D

9:00 BM BM D BM UBM D BM

10:00 D D U D D UBM D

11:00 U U D U D D U

12:00 D D D D D D D

1:00 D D D D D D D

2:00 U D U D U U U

3:00 D U D UBM D D D

4:00 D D D D D D D

5:00 BM BM BM D U BM BM

6:00 D D D U BM D D

7:00 U U U D D D U

8:00 D D D D U U D

Determine the Schedule

• Look at the 2 weeks data• Circle the BM’s on the sheet • Is there a pattern?

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

7:00 U U D U D U U

8:00 D D UBM D D D D

9:00 BM BM D BM UBM D BM

10:00 D D U D D UBM D

11:00 U U D U D D U

12:00 D D D D D D D

1:00 D D D D D D D

2:00 U D U D U U U

3:00 D U D UBM D D D

4:00 D D D D D D D

5:00 BM BM BM D U BM BM

6:00 D D D U BM D D

7:00 U U U D D D U

8:00 D D D D U U D

What Do You See?

• This child’s pattern is twice a day – around 9am and 5pm

• The focus time would be approximately– 8:45 to 9:05 and 4:45 to 5:05

Focus Time(20 minutes)

• Put your child on the potty 15min before anticipated BM. (Approx. 8:45am/4:45pm)

• Sit for 5min. Praise for sitting • Wait 10min, if not had BM, put your child back

on the potty for 5min • Again - Praise for sitting

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

8:45

9:00

4:45

5:00

Keeping Records

• During the first week do not alter the plan• Record when your child sits on the potty (we

use x for sitting only)• Record when your child has a BM in the potty

(P – BM in the potty!!!!!!)• Record when your child has a BM in the diaper

(D – BM in the diaper and what time the BM occured)

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

8:45 X X X D8:40 X X X

9:00 X D 8:55 P X P D8:55

D 9:10 D 9:10

4:45 X X X X D 4:45 X X

5:00 D 4:55 X D 4:55 P P X

D5:10 D5:10

Checking ProgressDo We Need to Change?

• Are the BM’s still around the anticipated time?– If yes – keep the same plan

• Is your child consistently earlier or later than the focus time?– If yes – consider altering the time to better match

your child’s body schedule

Consistency

• Follow the plan every day • Praise for sitting on the potty• Bigger praise for BM in the potty• During this time do not try to urine train• IF your child asks to go to the potty during

other times of the day it is OK

TIME FOR A CHANGE?

Is Your Child Ready to Urine Train?

• Begin Urine Training when your child consistently has a BM in the first sitting of toileting times

• And they have no more than one BM in the diaper during a typical week

Are You Ready To Urine Train?

• Change your child from diapers to training pants during the day

• You may want to “double up” on the undies since this may be messy

• Children are comfortable wetting in diapers. We need to remove this comfort to be successful. Now comfort comes from staying dry by way of wetting in the potty

Urine Training

• Determine a schedule of when your child is most likely to urinate– Look at two weeks data of when they have wet

diapers– Circle the U’s on your chart– Find 4 to 6 times a day when they are likely to

urinate– Add those times to the schedule you already have

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

7:00 U U D U D U U

8:00 D D UBM D D D D

9:00 BM BM D BM UBM D BM

10:00 D D U D D UBM D

11:00 U U D U D D U

12:00 D D D D D D D

1:00 D D D D D D D

2:00 U D U D U U U

3:00 D U D UBM D D D

4:00 D D D D D D D

5:00 BM BM BM D U BM BM

6:00 D D D U BM D D

7:00 U U U D D D U

8:00 D D D D U U D

New Schedule

• This child has 4 times they are likely to urinate – 7am, 11am, 2pm, and 7pm

• Add those times to your new schedule • Use the same focus times as before – start 15

minutes before anticipated urination, sit for 5 min, praise for sitting, 10 min later if still dry, sit for 5 min, praise for sitting

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

6:45

7:00

8:45

9:00

10:45

11:00

1:45

2:00

4:45

5:00

6:45

7:00

Record Keeping Again

• During the first week do not alter the plan• Record when your child sits on the potty

(we use x for sitting only)• Record when your child urinates (U)

or has a BM • Record if it is in the potty (P)

or in the training pants/diaper (D)

DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7

6:45 X X X X U P X U P

7:00 U D U D U D U D

8:45 BM P BM P X BM P BM P BM P

9:00 BM P BM D

10:45 X X X X X U P X

11:00 U D U D U D U P U D U P

1:45 X X X U D U P X U D

2:00 U D U D U P U D

4:45 BM P BM P BM P X BM P BM P X

5:00 X X

6:45 X X U D U BM P X U D U D

7:00 U D U D U D

Do We Need to Change?

• Are the U’s still around the anticipated times?– If yes – keep the same plan

• Is your child consistently earlier or later than the focus time?– If yes – consider altering the time to better match

your child’s body schedule

Consistency

• Follow the plan every day • Do not change the plan the first week• Use the same words/signs/pictures• Use the same toilet if you can. • If your child shows signs of a BM (squatting,

straining, going behind the sofa) or needing to urinate (holding themselves, crossing legs) at other times, go ahead and let him potty

Rewards

• Use rewards to increase desired behavior• Start small – for just sitting on the potty• Work up to sitting for 5 minutes • Then give for eliminating in the potty• Use immediate rewards – praise, high fives,

hugs, stickers, goldfish crackers, teddy grahams

• Have them close by (immediate)

Reward or Not?

• Decide ahead of time what gets reward• Make it easy to achieve• IF they do not do the behavior – do not give a

reward• Quietly lead your child out of the bathroom• Do not talk about the missed reward

No Attention (?)

• When they soil or wet their diaper/pants - quietly change them in the bathroom

• Try to focus on changing without making eye contact or talking to your child

• Then quietly lead them out of the bathroom• If your child is given attention for accidents

they are likely to continue

More Keys to Success

• Use the regular toilet from the start• If your child is too small, use a smaller seat

that sits over the regular one• Have a stool/bench to help your child get onto

the toilet and to place their feet on while on the toilet. This will help them feel more secure, and relax better.

• If you use a potty chair, keep it in the bathroom

Even More Keys to Success

• Limit distractions in the bathroom• Talk about the toilet and what you want your

child to do in a concise, non-demanding way• Sing a potty song• Wait patiently• Give reinforcements • Do not turn it into “playtime with mommy”

Phasing Yourself Out

• When your child is consistent with sitting on the potty, begin to phase yourself out

• Start by attending to other things in the bathroom

• Then wait at the door• Then leave the bathroom, start brief then

gradually go for longer periods of time

Phasing Out Rewards

• As your child is beginning to use the potty with consistency begin phasing out the rewards

• IF you have done stickers or food, begin to give them less often or move to High Fives

• Continue to tell your child that you are proud of him for going to the potty

ADAPTATIONS

Positioning• IF your child has high or low muscle tone, or if

they seem to be “wobbly” and lean often when sitting make sure their feet are on a firm surface, like a wooden stool

• They may need arm rests, or to hold onto the counter/wall

• They may need to sit facing the back, straddling the toilet, with arms on tank– This is also good for boys to learn aiming

Picture Schedules

• If your child learns better from pictures than from words you may want to have a picture schedule for toilet training

• It should be brief but contain the information your child needs

• It could be in a book format for reading OR in line format that you have on the bathroom wall easily visible from the toilet

Vision Impairment

• The same readiness signs apply– Follow simple directions– Sit in a chair for 5 minutes– Stays dry for 1 ½ hours

• The same positioning tips apply– Have a firm surface for their feet – wood bench

Looking With Your Hands

• The child with severe vision impairment will need to touch and feel the toilet and toilet paper with your hands guiding them

• They may need to touch the bowel movement or urine to understand

• This is ok at the beginning but should not become a part of the regular routine

Constipation

• Liquid Intake– Most children need 1 ½ ounces of fluid per pound

of body weight– Hot weather, fever, and excessive drooling can

cause that to go to 2-3 ounces per pound• Fiber Intake

– Add fiber to your child’s diet through fresh fruits, vegetables, whole grains, and cooked beans

DAYCARE / PRESCHOOL

What Do They Do?

Habit TrainingToken System

Potty Day

Habit-Training Program• Once a day (usually in the morning) the child

drinks liquid (2-4oz) prior to toileting• The child sits on the toilet until they urinate in

the toilet. (Up to 30 minutes) They may need to stand up or walk in the bathroom a minute

• If they have not urinated within 5-10 minutes more liquid is given (8-10oz) while on the toilet

What Else?

• Wait until the child urinates.• When the child starts to urinate stay quiet,

then praise them for urinating in the toilet.• IF they have an accident while they are

standing, try to catch it in a cup and put it in the toilet. Do Not scold.

• Do this once a day until they are urinating within 2-3 minutes of getting on the potty

Continuing

• Add toilet times during the day• Start with one additional, then when they are

urinating within 2-3 minutes each time add another

• Eventually your child should urinate whenever you put them on the potty. This means that they are “Habit Trained”

Moving to Independent

• Once your child is habit trained, teach words, signs, or use of pictures so they can let you know when they need to potty

• Give them reminders or suggestions but do not take them until they ask. When they have accidents change them in the bathroom as quietly as you can without giving attention

Completing the Process

• Start rewarding them for being dry during the day.

• Check them throughout the day when you know they will be dry and give them a small reward for being dry

• As your child gets more independent, space out your rewards

Token System• The Token system rewards the child with tokens

each time they successfully “go potty”• They are usually star charts or sticker charts• Each time the child goes to the potty they get a

star or sticker added to his chart• When they achieve a set number of stars they get

a reward – treat, outside play, special toy, special video

• As the child becomes more successful, more tokens are required to achieve the reward

Potty Day

• Similar to the system we discussed to start• The child is taken to the potty at times during

the day when they are most likely to go– First at school– After lunch– After nap

• The child is given a reward for going potty

Night Time

• When your child is successful during the day, you may start night time training

• Take your child to the potty before going to bed, then wake them once during the night

• Sit with them until they urinate (10 min only)• If they wet just before waking, begin waking

them 30 minutes early and take them directly to the potty

Last Minute Notes

• Potty training usually begins sometime after 18 months of age (when the child is ready)

• Potty training should begin by age 5 • When training, make sure all caregivers,

including school caregivers, are expecting the same things from the child

• Do not flush while the child is sitting on the toilet.

Reward Yourself for Sticking to the Plan

(This is a difficult time for the trainer as well as the trainee, so do not forget to give yourself

rewards at whatever interval you need)

References - Books

• Baker, Bruce and Alan Brightman. Steps to Independence: Teaching Everyday Skills to Children with Special Needs. 4th Ed. Baltimore: Brookes Publishing, 2009. Print.

References - WEB

• Wilson, Mike. “Generic Habit-Training Program.” BBB Autusm Support Network. Web. www.bbbautism.com/pdf/article_9_generic_habit_training.pdf

• “Potty Training Your Child with Autism: Ready, Set, Go!”. Autism Asperger’s Digest Magazine 2010. Web. http://www.autismdigest.com/Portals/0/docs/Article-Toilet%20Training%20Ready%20Set%20Go.pdf

Joshua as a little guy

Joshua in his crib

Roar!

Joshua with his backpack

Joshua - Happy

Joshua Contemplating

Joshua’s Family

Joshua and his brother

Potty Training Chesca

Why we started

Someone told us we couldn't

Caught in the act.

When we started

Two years old

Sitting up

Starting to walk

Still non-verbal

How we started

Internet

Tools

Schedule

What we could have done better

Consistency

Consistency

Consistency

Training pants

Tools

Potties

Videos

Charts

Potty Watch

Problems

Health problems

Working with school

Regression