1. Rubinstein-Taybi syndrome Readiness for Toilet training Charlotte Mawby Independent Paediatric Continence Nurse May 2016

2. Key points Assessment : Is your child ready Plan: Toileting program
Support: child – family – staff
Referral: if required

3. Skills not disability

4. What is normal usual age a child gains control
Control of bowel asleep ~ 1 yr
Control of bowel awake ~ 2 yrs ?
Control of bladder awake ~ 3 yrs
Control of bladder asleep ~ 5 yrs 4

5. Habit trained or toilet regulated
(Clean and dry when supported by adult)
Uses the toilet when taken but does not indicate or request to use it
Usually develops later into independent toileting
(inline with other developmental milestones)

6. Why some children struggle
1-2% have an underlying organic cause
Limitation due to Physical / Learning abilities
Healthy bladder & bowels
Equipment
Realistic expectations
Appropriate teaching resources
Offer toilet training support
Behaviours & Compliance

7. Anatomy rectal and anal sphincter
Empty

8. Anatomy rectal and anal sphincter
During defecation

10. Anal sphincter mechanism
during defecation

12. Drinking habits in children
Often limited fluid intake at breakfast
Little or no fluid taken during school day
Fluid intake on return home until going to bed:
reduced daytime opportunities to practice toileting skills
very wet night nappy

13. Daily intake 5 years 10 years 15 years 1000 mls 1500 mls 2000 mls Age
Quick reference
5 years
10 years
15 years
1000 mls
1500 mls
2000 mls
Age
Litres
6 drinks a day
5 drinks a day
Child
1-3
0.9
150 mls
180 mls 5
1.0
170 mls
200 mls 8
1.3
220 mls
260 mls 10
1.5
250 mls
300 mls 12
1.7
280 mls
340 mls 15
2.0
330 mls
400 mls 13

14. Healthy Bowels what type how often Size – Diameter  4.5 cm
pain, distress
toilet, nappy, pants
pants: clean ~ soiled
medication
Normal
type 4 ~ 3
3 x a day to 3 x a week

15. Colon – mega colon ‘diameter of stool’

16. www.promocon.co.uk in section publications

17. 5 point Toilet training readiness assessment
Ability to sit on the potty / toilet appropriately
Bladder to hold wee for at least 1 hour
Bowel that is not constipated
Some awareness of being wet
Some awareness of what toilet training is about
Ref: Continence promotion for children with learning difficulties. J Rogers. (Shiloh healthcare)

18. abilities / skills mobility dressing / undressing skills
response to basic commands
indicates needs ~ favourite dvd, books, foods, soiled, wet
any appropriate use of potty / toilet
abilities can be hampered by behavioural issues

21. Equipment

22. Equipment

25. Specialist equipment
Smirthwaite Rifton: HTS Rifton: Blue wave

26. Accessible toilets
Radar key

27. Complexities of toilet training
Carer to understand / predict child’s needs
Developing self help skills:
door opening
removing & replacing clothing
getting on / off the toilet
toilet sitting (1 minute for each year of age Max. 10)
use of toilet paper
flushing toilet
wash and dry hands
Keep the boys sitting until bladder & bowel routine is established

28. Advice Appropriate fluid intake Routine: take to toilet at
regular intervals (5-6 x a day)
Sit & relax – bottom on toilet
seat, in order to perform
Extra sitting time after meals
to encourage bowel action
Don’t rush, wait until finished

29. Disposable
Nappy: Slip: Form Pants: pull ups
Comfort: Flex Tena 4 men

30. rewards

31. Teach hand over hand wiping
Bottom wiping
Teach hand over hand wiping

32. Washable products Cudri : Abena : Ganmill

33. Swim wear
Incy wincy Ltd
In-confidence
PHP baby
ERIC

34. Toileting behaviours Constipation  Poos in nappy or pants
In the play ground, behind the sofa
Smearing in nappy, pants, wall
Where are soiled nappies / pants changed
Lying down / standing up
Regular toilet sitting for boys & girls
Early intervention - to change behaviour patterns
Child to stay in bathroom until routine is complete, assisting with bottom wiping, flushing, hand washing

35. Consistency - Behaviours
Regular toilet sitting
1 minute for each year maximum 10 minutes
Child must understand desired behaviour
Reward desired behaviour: sitting > performing
Give praise/ reward - desired behaviour
Agree a reward system - keep it simple
Make it fun

36. Targets Communication - verbal & pictorial prompt
Child to go into toilet area / cubicle
Assist with removal of clothes
Getting on / off toilet
Appropriate toilet sitting
Bottom wiping
Assist with replacement of clothes
Hand washing

37. Working towards success
Include toileting into the Childs Individual Education Plan / Statements
Resources to aid communication
Aids for safety & comfort when using a toilet
Access into and onto the toilet
Agreed & written ‘care plan’ – all care settings
Agree use of appropriate products:
washable ~ disposable 37

38. Facilitating toileting program
Ensure: Healthy bladder & bowels
Appropriate equipment. Provision & usage
Written information, helps ensure consistency in all care settings
Support for training in all care settings
On going support, assessment & planning

39. Toileting Plan - 1 Agree- routine – regular toilet sits getting up
arrival at school
mid morning
before / after lunch
before home time
before evening meal
before bath / bed

40. Toileting Plan - 2
Agree communication: spoken, signing, PECs, visual timetable, talking photo album
Warning time – prior to
Visualisation of sitting time – egg timer
How sitting time will be increased
Reward: verbal – item – object

41. Gauging success How many wet – soils per day
Any reduction/increase in wet or soiled clothes
Indicates when wet / soiled
Can stop & start - in pants on toilet
Change in bowel routine
Ability to learn v behavioural issues
Won’t sit, won’t wear pants, won’t ………

42. Any questions ?

43. Additional support ERIC 0845 370 8008
Help line: Education and resources for improving childhood continence
Promocon
Promoting Continence and product awareness

44. Resources
Education and Resources for Improving Childhood Continence product catalogue
Bedwetting: a guide for parents. ERIC
Including me

45. www.promocon.co.uk/talkaboutpotty.pdf (Rogers.J. 2007)
Resources
(Rogers.J. 2007)
(Rogers.J. 2004)
(Rogers.J. 2005)
(Rogers.J. 2004)
(Rogers.J. 2004) 45

46. Resources Books My very own potty time –girls / boys
Big girls / boys use the potty
The potty book for boys
Potty time training pack
DVD
Bear in the big blue house
Sesame street: Elmo’s potty time
Potty power
I gota go!

47. Name
Class
Teacher
Drinks
9 :00 : 10:40: 12:20 14:40
Arrival at school : Break : after lunch : before home
Equipment
Targets
Communication - verbal & pictorial prompt
Child to go into toilet area / cubicle
Assist with removal of clothes
Getting on / off toilet
Appropriate toilet sitting
Bottom wiping
Assist with replacement of clothes
Hand washing
Record - toilet activity / progress

48. Name
Class
Teacher
Drinks
Equipment
Behaviours in toilet area
Behaviours when pads are changed
Concerns about introduction of toileting program
Record - toilet activity / progress

49. One step at a time
A parents guide to toilet skills for children with special needs
Continence Foundation of Australia