1. Toilet-Training A Child with a Developmental Disability: A Family-Focused, Low Intensity Approach Susan Hepburn, Ph.D. Clinical Psychologist Asst. Professor/Director of Research JFK Partners/Dept. of Psychiatry University of Colorado at Denver and Health Sciences

2. Acknowledgments  Association of University Centers for Excellence in Developmental Disabilities (UCEDD)/JFK Partners  Developmental Pathways  Teachers and administrators in Cherry Creek School District and Littleton Public Schools  Families of children who have participated in individual and group toilet-training interventions

3. This talk is dedicated to Nathaniel Roberts, a dear boy, who taught us much about social motivation and the joys of independence. We develop this work in his memory.

4. Overview  Part I: Philosophy and Core Principles  Part II: Getting Ready: Changes we Make While the Child is Still in Diapers or Pull-ups  Part III: Practicing in Routines and Building Habits  Part IV: Working on Pooping in the Toilet  Part V: Getting Rid of Diapers and Pull-ups  Part VI: Reflect on Your Progress

5. Part I: Philosophy and Core Principles

6. Philosophy PatiencePersistenceHumorCreativity

7. “Toilet training in less than a year”  “It’s a marathon, not a sprint” -- Gary Heffner, father and advocate

8. Many people believe… 1. Your child has to be “ready” 2. More trips is always better. 3. You have to get rid of the diapers to make progress. 4. Children need to be able “tell someone” that they have to use the bathroom as a first step. HOWEVER….

9. Core Principle I  We don’t hold tightly to “readiness” criteria We think that children learn through practice within their natural routines and don’t necessarily have to be “ready” for us to make the toileting issues less stressful for the family. We think that children learn through practice within their natural routines and don’t necessarily have to be “ready” for us to make the toileting issues less stressful for the family. We use a “slow and steady” approach, allowing us to adjust our strategies depending upon the child’s progress. We use a “slow and steady” approach, allowing us to adjust our strategies depending upon the child’s progress. We emphasize the importance of the parents being ready – particularly when it comes time to remove the diapers or pullups. We emphasize the importance of the parents being ready – particularly when it comes time to remove the diapers or pullups.

10. There is always something we can do to get to the next step….  Within your regular routines  Without removing the diapers or pull-ups  For most children, it makes sense to start toilet training when they have a developmental age of about 15 months

11. Core Principles II  More is not always better. Too many unsuccessful trips to the bathroom may actually slow progress. Too many unsuccessful trips to the bathroom may actually slow progress. If a child is overwhelmed by the training process, problem behaviors and resistance will occur. If a child is overwhelmed by the training process, problem behaviors and resistance will occur. Parents tell us that intensive approaches are difficult and stressful. Parents tell us that intensive approaches are difficult and stressful.

12. Core Principles III  Getting rid of the diapers happens towards the end of the process – most of the training is done with the child still in protective gear. For a child who doesn’t “feel” the wet diaper or become uncomfortable being soiled, removing the diapers doesn’t speed up the training process. For a child who doesn’t “feel” the wet diaper or become uncomfortable being soiled, removing the diapers doesn’t speed up the training process. Several steps and concepts need to be mastered before diapers should be removed. Several steps and concepts need to be mastered before diapers should be removed. By minimizing the amount of messes parents deal with, we hope to reduce the stress of the process. By minimizing the amount of messes parents deal with, we hope to reduce the stress of the process.

13. Core Principles IV  Teaching the child to communicate that he or she needs to go the bathroom often comes toward the end of the training program. Communication is always built into the routine and is practiced, but not “required” Communication is always built into the routine and is practiced, but not “required” It is often helpful to have a nonverbal way of signaling the need to go – although we can’t prompt a child to verbally request the bathroom, we can prompt a gesture or picture exchange It is often helpful to have a nonverbal way of signaling the need to go – although we can’t prompt a child to verbally request the bathroom, we can prompt a gesture or picture exchange

14. Part II: “Getting Ready” First Steps in almost any toilet-training intervention

15. 1. Observe  Make lists of foods/drinks your child usually consumes  Note the approximate times of day the child is eating/drinking  Look for anything unusual in frequency or consistency of child’s pee and poop

16. Are there any behavioral signs that your child needs to go?

17. 2. Ask the Pediatrician  Dietary recommendations  Are supplements needed to prevent constipation?  Any possible GI issues or treatments to consider?

18. 3. Consider Dietary Changes  Lots of fluid: water or juice are best!!  Lots of fiber: Age plus 5 grams! spread across 3 meals  Less dairy

19. 4. Consider small changes in daily habits  Dress child in easy to remove clothing  Change as quickly as possible  If possible, change diapers in (or near) bathroom  Show child that waste goes in toilet  Have child flush and wash hands at diaper changes

20. 5. Interactions with Your Child  Decide on your toileting words and use them every day across people and places  Be very matter-of-fact and positive about using the toilet  Be very positive about their efforts and cooperation – do not emphasize producing into the toilet, but emphasize willingness to try  Try to make sure that something good or fun happens when you leave the bathroom

21. 6. Showing and Telling Kids About Toileting  Allow child to watch mom or dad or siblings  Look at toileting books and videos together  Listen to toileting songs together  Teach toileting through play  Make a homemade book about toileting  Make a home movie about toileting

22. 7. Think About Rewards for Participation  A fun activity – particularly good if it is natural to the child’s schedule – for example – going outside to play  Special food or drink  Special toys  Special sensory experiences  Target practice (cheerios, sinkems, wax paper) To improve the power of your rewards: try to limit access only to toileting times!!!

23. 8. Set Up Your Bathroom  Make it a pleasant place to be (smells good, warm, perhaps music is playing)  Make sure the child is comfortable on the toilet and if needed, get a potty chair insert  Provide foot stool or other way for child to feel stable while seated  Make sure your rewards are nearby  Put up some visual supports

24. More on Visual Supports  Visual supports for the overall routine and when you will visit the toilet  Visual supports for the steps within the routine  Transitional object  Visual reminders  Visual supports to clarify how long he has to sit there  Visual supports to show what will happen when it’s over

25. 9. Think about who can help out….  Spouse/partner  School  Daycare providers  Grandparents  Respite staff And talk to them about what you are trying to do.

26. Part III: Practicing In Routines and Building Habits

27. How to Trip Train  You set the schedule  You train the child’s body to go during your schedule  For peeing: trip is 10-30 seconds on toilet  For pooping: “Sit for Six” **for children with low muscle tone, they may need longer to pee or to poop

28. Trip Training: Time to Go!  Within the flow of your regular routine, while child is still wearing diapers or pull-ups: prompt child to go to the toilet; encourage but don’t require that child communicate urge to go  Request that child sit for a very brief time, but don’t force it! Try to distract with songs or favorite toys while practicing sitting  Complete the entire routine and after drying hands – give reward (or go to a cool next activity) simply for cooperating  If child actually If voids  big reward

29. Choosing the Times to Go  DO CHOOSE: A clear and predictable activity for the “before” time, such as dinner, or coming in from outside A clear and predictable activity for the “before” time, such as dinner, or coming in from outside A fun activity for the “after” time A fun activity for the “after” time  DO NOT CHOOSE: To interrupt the child’s favorite or preferred activities, such as tv or computer time Times in the day that are too hectic for you to realistically do

30. So, we have to do 3 things:  Try to predict how long between input (drink) and output (pee)  Pick natural transitions – or times when child is already changing from one activity to another – for example, coming in the door from school  Practice making trips to the bathroom within routines no more than 3-6 times per day.

31. A Toileting Routine  Regular routine or transition (such as coming inside from school)  Visual reminder or physical cue to go to the bathroom  Quick 30 second to 1-minute trip, following all the steps of the routine whether or not he has produced anything  Leave the bathroom and something good or fun happens

32. Practice, persist, and persevere  Give the routines time to take hold  Be as consistent as you possibly can  Forgive yourself and others when it just can’t be done  Remind yourself that this is a hard skill and will come with time and practice  Change up the rewards

33. Example of steps of a routine  Walk to bathroom  Pull down pants/underwear  Sit on toilet  Go in toilet  Wipe  Stand up and dress  Flush  Wash hands  Go play

34. Another tip….  Look for times when your child is really motivated for something (such as wanting to watch a favorite TV show) and develop a routine: FIRST POTTY ……..THEN TV

35. Part IV: Working on Pooping in the Toilet

36. Steps  Continue to monitor and treat any constipation issues  If child has low muscle tone, talk to an OT or PT about exercises that can strengthen core muscles.  Choose 1 toilet trip per day that will be a “Poop Trip” The child will be asked to stay a few minutes longer (about 4-6 minutes) The child will be asked to stay a few minutes longer (about 4-6 minutes) The adult will need to be there (at least in the beginning). The adult will need to be there (at least in the beginning). Choose a very special reward for pooping. Choose a very special reward for pooping.

37. Some Additions to the Routine for Poop Trips  Consider exercise just before the trip  Consider taking the child’s hand and applying pressure to their belly to focus their attention on that area  Try very hard to interrupt accidents and get them onto the toilet if already pooping If they get a tiny bit in – it’s a success!! If they get a tiny bit in – it’s a success!!

38. If a child is afraid of pooping in the toilet  We often do increased work on the social stories, home movies, and other ways to help them to get used to the idea  We gently encourage them and support them to face their fears  We often start with small steps and help them to desensitize to what’s scary  Sometimes we can provide some environmental supports to reduce loud noises and other scary parts

39. Part V: Getting Rid of Diapers and Pull-Ups

40. When do I get rid of the diapers?  No right or wrong answer here  Varies a lot by child’s style  Some need us to make a clean break  Others maintain them throughout 75% of the training process  For many children with sensory and/or motor issues: Getting rid of the diapers may not help the child to learn the skill more quickly; Getting rid of the diapers may not help the child to learn the skill more quickly; BUT …. can actually increased stress and frustration

41. We want to get rid of the diapers when: We want to get rid of the diapers when:  The child is cooperating with the routine, and has successfully urinated in the toilet several times.  We can commit 3 weeks to really good consistency and follow-up.  We know there will be accidents and we are prepared to try to use those accidents as chances to teach the skill.  If at all possible, best to do while child is in school or a program where others are also willing to make this step. This helps the child learn the skill more fully and transfer it to other places more easily.

42. Choose a Good Time in Your Family’s Life  Consider: your work schedule, other children, holidays, special events and other demands that may make it easier or harder to begin  Remember: First 3 weeks are very important and most labor intensive!  It has to work for the family – if we can persist through this difficult phase we are more likely to be successful!!

43. Decide How to Handle Accidents  Do not punish or scold!!  Option 1: Gentle correction and change  Option 2: Immediately place on toilet and R+ if just the tiniest bit gets in  Option 3: Allow to feel sensation and involve in clean-up

44. Remember, many kids with developmental disabilities need longer to mature into being dry at night. When we remove the diapers during the day, we often keep them on at night.

45. Part VI: Reflect on Your Progress And Make Changes As Needed

46. After 3-6 weeks: How’s it going? Do you need to modify your approach?

47. Options for making changes after 3-6 weeks of trip-training  Play with the schedule  Change up the rewards  Change the social context  Change diet  Find another way to teach the connection – music, videos, modelling, play Once you’ve decided on the changes, give them 3-6 weeks to work and re-evaluate. Are you seeing improvement?

48. If you are approaching 3 months of trip-training and not seeing a lot of change…  Sometimes….we pause, take a break from working on this skill and come back to it a little later, preserving 1 routine a day if at all possible  Sometimes…we identify a problem and provide some new instructional component or change in our teaching methods  Sometimes….we move to a more intensive intervention, like eliminating the diapers and learning through accidents  Sometimes….we decide to stay the course. It all depends on the child’s style and all of the other variables that affect this skill.

49. Conclusion