Monthly Archives: August 2016

Is Slow Progress In Toilet Training A Failure?

Children that are slow to learn independent toileting come in many flavors.  There are the children who resist training; they just don’t want to sit on the potty and rewards haven’t made them excited to train.  Then there are the kids who develop fear of painful bowel movements.  And also the children with language and/or cognitive delays, who learn everything at their own pace.

Some kids in the last group spend a lot of time at the stage of scheduled toileting.  They can get to the potty, manage clothing independently or with only a few hints, and wipe, and some can even recognize that they need to “go” without being asked.  They just don’t put the whole thing together.  Is that a failure?

I don’t think so.  I believe that some kids stay at one stage for a reason, and sometimes their reason isn’t clear.  The kids with fears or lack of motivation need an adult to rethink these situations and take action.  A diet change, the use of probiotics or more fluids can make a huge difference.  Finding out that social reinforcers like an older cousin’s comments about the importance of using the toilet can be the key to motivate a toddler.  The biggest mistake, I think, is thinking that there is nothing that can be done. For a child that has fears or avoidance that aren’t addressed , he can assume that this situation is OK with his parents, or that no one is able to help him move forward.

What about the children that learn at their own pace, who take a long time to learn independence in most skills?  I think that being independent but needing to use a scheduled toileting plan is still a big accomplishment, and the need for a schedule can be phased out over time.  Firm routines help, so does pairing toileting with another regularly occurring event like getting dressed, and fading the prompts away one at a time.  If you think about your own behavior, didn’t your mom tell you to “go” before you left the house, regardless of how many times you told her that you had just gone?  Toileting schedule.  Or looking at the clock and using the bathroom before you board a plane to avoid being locked in that nasty in-flight potty?  Scheduled toileting again.

So take another look at your child’s progress and reconsider how you characterize the situation.  It may not be as bad as you think.

 

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Low Tone In The Summer: Why The Heat Affects Your Child’s Safety

If you have a child with low muscle tone, you may have seen them wilt like flowers in the sun.  Even if they are well-hydrated, even if they are having fun, they just can’t run as fast or sit as steadily when they are warm.  Add a SPIO vest or other compression garment, and the tripping and falling seems to happen more often.  What gives?

Just like a warm bath relaxes your tight shoulders after a long day, heat relaxes muscles.  It doesn’t matter if the heat is environmental or neutral warmth, the kind that is generated by your child’s own body and is held in by the SPIO or her clothes.  It is still heat.  And some kids with low tone don’t sweat efficiently, using the body’s natural method of heat reduction.  This isn’t a minor concern if you have a child that is pretty unsteady on a cool day.  Kids with low tone that are out and about in the heat can become so floppy that they stumble and get injured.  That is a problem.

What can you do?  Well, you may not be able to wear that SPIO in the heat.  Try kineseotaping instead.  (ask your OT or PT if they have been trained in it’s use).  Alternate time in air conditioning and time outside.  Offer cold drinks and ice pops if they can lick and swallow an ice pop safely.  Dress lightly and choose clothes with fabrics that evaporate body heat.  Choose shoes that offer more support, not Crocs or sandals.  This is not the time to pick the least-supportive footwear.

Most importantly, monitor them for safety and be aware that children really cannot judge whether or not they should come in and cool off.  They are counting on you to keep them safe!

Why Do Some Kids With ASD and SPD Refuse Toilet Training?

Toilet training is one of the few self-care skills that fall primarily on special needs parents.  Speech therapists, feeding therapists, occupational therapists and ABA instructors all do assessments and create plans.  Hints on toilet training from your therapy team are often very helpful, but “the boots on the ground” are yours as a parent.  You are the one that deals with it when *&%$ happens, as it most certainly will!

Many parents find themselves with children that do not cooperate or become defiant to the entire process of training, regardless of their level of cognitive, sensory or motor involvement.  A child with profound issues can cooperate well, and a child that is in a integrated class can be steadfast in not participating.  What gives?

  1. Sensitivity to multi-sensory input:  The noises, smells, even the lights in a bathroom can be mildly to very irritating to sensitive children.  They may not verbalize it, even if they have lots of language; they just want out.  Try to minimize what you can, and use the sensory calming techniques your OT has shared.  Ask for all her good ideas!
  2. Sensory seekers that aren’t motivated to remove wet or smelly diapers, don’t register the experience, or actually want to explore what is in that diaper.  Some children are at the other end of the sensory spectrum, and may not find the odor and feeling of a soiled diaper offensive or even that noticeable.   See Pull-ups do a wonderful job of reducing the sensory input, so try training pants with a leak-resistant cover. Just like a younger typically-developing toddler, some ASD and SPD kids “smear”, which is exactly what it sounds like: decorating the room and/or themselves with their feces.  This is a behavioral issue with older children, but it also suggests that the motivation to get trained isn’t going to include wanting to be rid of the diaper and it’s contents.
  3. They dislike being exposed to room-temperature air, and wiping/being wiped.  These kids probably have always dislike diapering.  They might avoid you after they have had a bowel movement to avoid being changed.  You may have had to become an expert in the “fast change” so that they are not totally hysterical.  Well, sitting on the pot with their pants off for a while and learning to wipe might be even harder than being diapered.  Try warming the room, get a warmer for the wipes (these exist) and make sure that you communicate that this doesn’t mean they have to sit there for a long, long time.
  4. They hate the feeling of the clothing sliding over their legs.  Time to work on reducing their tactile sensitivity.  It can be done; ask your OT.  And find some super-soft clothes for the toilet-training period.  Fleece shorts, anyone?
  5. Sitting on the toilet seat feels like they are perched over a big scary hole.  Children with poor spatial awareness or poor proprioception aren’t good at judging how large the opening is or how deep.  Add some instability with low tone, and you have a recipe for fear.  Then flush the toilet while they are still sitting, or standing nearby, and that potty seems like it could suck them down!  Try a potty seat and gradually move them over to a toilet once they are confident and independent there. Do more homework exercises on core stability and postural control, and don’t forget vestibular activities from OT.
  6. Without a clear sense of time, sitting there seems like it takes forever.  Kids can have no sense of how long something they don’t enjoy will take.  Use a visual timer, the microwave timer, or your smartphone timer.  My iPad has a visual countdown clock to see when time is up.

These are the most common that I have encountered.  Some of my posts on toilet training children with low muscle tone will also apply to kids with ASD and SPD, so check out  Low Tone and Toilet Training: How Your Child’s Therapists Can Help You  and Low Tone and Toilet Training: The 4 Types of Training Readiness.

The Practical Guide to Toilet Training Your Child With Low Muscle Tone is finally available! My 50-page e-book is for sale on my website  tranquil babies  (or buy a clothbound hard copy if you live in the U.S.) to help you with training.  Check out  The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Help Has Arrived!  to learn more about my book and how I can help you navigate potty training without tears!

 

 

Low Tone and Constipation: Why This Issue Delays Toilet Training Progress

Kids with low tone and sensory processing disorders are not the only children who struggle with constipation, but it is more common for them.  The reasons are many:  low abdominal and oral tone, less use of available musculature because they use compensatory sitting and standing (the schlump, the lean, the swayback) patterns, and even food choices that have less fiber.  If you struggle to chew and swallow, you probably aren’t drinking enough and eating those fruits and veggies that have fiber.  Sucking applesauce packets may get you Vitamin C, but it has pulverized all that fiber.  Now add discomfort with the sensory experience: the smells, feelings, sounds of bathrooms and using the potty.  It can all be too much!

Without fluids, fiber and intra-abdominal pressure to support peristalsis (the automatic contraction of the intestines), children with low tone are at a huge risk for constipation.  And constipation makes pooping harder and even painful.  Sensory overload makes kids agitated, distracted, and sometimes even aggressive.  Not good for learning or letting it go into the toilet.  Hence, resistance and even fear of pooping, and therefore more stress and withholding of stool.  A really big problem, one that you may have to get your pediatrician’s assistance to solve.

It can change.  Here is your secret weapon: your child’s occupational therapist.  If you haven’t been involved in your child’s therapy before, this might be the time.  Research has shown that sensory-based issues can contribute to toileting problems, and OTs are capable of evaluating all the sensory and motor-based contributors.  While  your pediatrician gives you recommendations on diet, laxatives and more, your OT can help your child stay in the alert-but-calm zone where digestion is relaxed, get better core stability to help push that poop along, and adapt the toileting experience for minimal sensory aversion and maximal sensory perception.  Take a look at Low Tone and Toilet Training: How Your Child’s Therapists Can Help You and Low Tone and Toilet Training: The Importance of Dry Runs (Pun Totally Intended).

Update:  Many of my clients have been successful with a creative combo approach:  they use stool softeners, they limit refined carbs (sorry, Goldfish crackers are cheese plus refined carbs!), ensure lots of fluids and then add some tasty fiber.  Prunes covered with chocolate have been popular, but beware the results of too much of a good thing!  They use abdominal massage and make sure that their physical and occupational therapists are working those core stabilizers.

There are medications that improve gastric motility, but they aren’t always tolerated or even prescribed for small children.  Pediatricians are very hesitant to be aggressive with a small child that could dehydrate in a few hours of diarrhea.  Find a doctor that listens to you and is creative.  My suggestion?  Think outside the box and consider an osteopath.  They are “real” doctors, but they have more training in alternative and manual treatment approaches.

Good news!

My book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, is done and available at  Your Therapy Source ( a terrific site for parents and therapists!) as well as on my website, tranquil babies !!  Just click on the “e-book” section, and start making progress with your child today!

I include detailed readiness checklists and a full explanation of how to train your child in all aspects of toilet training.  You will know how to get the right equipment, what clothes to use so that dressing doesn’t derail your child’s best efforts, and how to deal with defiance and distress.  And yes, constipation is addressed in more detail than in this blog post.  It may turn out to be only one of the issues that you have to confront.  Don’t worry, help has arrived!

If you want a hard copy, contact me through my site and request a mailing address for your payment.

            As I say in my book:  be prepared, be consistent, expect to practice, and be positive that you and your child can do this!

 

 

 

 

What’s Really Missing When Kids Don’t Cross Midline?

If I had a dollar for every teacher who remarked on a child’s inability to cross the midline of his body (left-right midline, not top/bottom midline),  I would be writing this post from my beachfront condo in Hawaii.  Here is what problems crossing midline can signify, what other issues are often seen with these kids, and how to help them.

First, an inability or unwillingness to reach across the midline of your body to obtain something that you want in any position (sitting, standing,etc) would be considered  developmentally delayed after the child has been able to maintain a stable position and play with both hands at midline.  This is typically seen at around 4-5 months for prone (tummy-down), 8 months for sitting, 13 months for standing.  Those estimates depend on typical timing of achieving independence in maintaining each of those positions.  In each of these, a child will usually progress from only using one hand to reach while supporting herself on the other arm, then playing with both hands in the center of her body without any support, and then reaching across her belly to get something she wants on the other side.

What would delay this natural progression?  Well, obviously any physical issue such as low muscle toner spasticity.  That would make a child less stable and less likely to be able to shift her weight and control reach.  Any asymmetry in controlling trunk or limbs, as is seen with hemiplegia or congenital issues such as Erb’s palsy and torticollis will reduce reach to one side.  Problems with vision such as strabismus may contribute to ignoring one side of the visual field, and problems with hearing could reduce awareness to one side as well.  These reasons are often obvious to parents, teachers and therapists.

The last two are the hardest to see:  limited core stability and limited sensory processing.  A child who lacks good abdominal tone and strength  is less likely to rotate to reach across their body and then return to a balanced position.  That child moves in a more linear plane: forward and back, tilt to the side and return to vertical.  A clever kid can look pretty good if he compensates well, and if he tells you that he “just doesn’t like that game”; the one that requires rotary control.

Sensory processing limitations like poor proprioception and poor vestibular registration and tolerance can make a child either less aware of a shift in movement or overly sensitive to that movement.  Turning their head as they look and then turning back can be irritating or even make a child with poor vestibular processing a little dizzy.  They learn not to do that if they can avoid it.  Same with poor proprioception.  If you fall over every time when you are sitting, it is easier to play with the toys that are only a forward-reach away, and be happy with them.

This pattern of avoidance can become a habit after a relatively short time.  Children whose skills have improved may still habitually turn their whole bodies to reach instead of rotating.  They just don’t never integrated that smooth automatic control.  After a while, they may show signs of poor core stability from lack of use, without any underlying tonal issue.

How can you help?  By knowing that core stability, tone, sensory issues or asymmetries as  issues that contribute to struggles with handwriting, ball play, and stair climbing and more.  By addressing the underlying issues with therapy and targeted play, rather than accepting that this child is more excited by books than sports.  And not assuming that if you hound them with reminders to “use your other hand” that it will work.

Low Tone and Toilet Training: How Your Child’s Therapists Can Help You

Over the years as an occupational therapist, I have been giving parents hints here and there.  Writing my e-book  this fall, and preparing an e-course (coming soon) to support families makes me realize that some clients did not ask me very many questions while they were toilet training their child.

So….Are there aspects of therapy that can help you with toilet training?  Yes indeed!  Does getting more therapy mean that your child will automatically be trained earlier and more easily?  Unfortunately, not really.

When it comes to potty training, you can bring a child to the potty, but you can’t make him “make”.  Toilet training is a complex skill, and even the best therapy will still only prepare all of you and develop important skills needed for this skill.  Bringing it all together is still the job of the parent or the full-time caregiver that creates and executes the plan. Waiting for readiness?  Read Waiting for Toilet Training Readiness? Create It Instead!  to understand what you can do today to inspire interest and build skills. Thinking that it’s too soon?   How Early Can You Start Toilet Training?  will shad some light on what is really important when you are wondering if your child is old enough.  If you are wondering if your child’s diagnosis is part of the issue, take a look at Why Do Some Kids With ASD and SPD Refuse Toilet Training?  And finally, if you are eager to move into night-time training, read Why is Staying Dry at Night So Challenging For Some Children? for support at the finish line of toilet training.

Here is a list of what therapy can do to support you and your child for toilet training.  If you haven’t heard your therapists discussing these treatment goals/approaches, you might want to share this post with them.  They may be more focused on other very important skills right now, but always keep your discussions open and inform them that you are planning on training.  Most therapists are very eager to support families whenever they can with whatever goals the family has.

  1. Core stability for balance, abdominal strength and safety on the toilet.  Most kids with low tone do not have great core stability, and this is where the rubber meets the road.  A weak core will put a child at greater risk of falling or feeling like he will fall.  It is harder to relax and pee/poop if you are afraid you will land on the floor.
  2. Clothing management and hand washing.  No child is really independent in using the toilet if someone else has to pull clothing up and down.  Washing hands is a hygiene essential.  Time to learn.
  3.   Good abdominal tone.  See #1.  Helps with intestinal motility as well.  That is the contraction of smooth muscle that moves the poop through the colon and on out.  My favorite hack is the use of kineseotape in the classic abdominal facilitation pattern.  All but one of my clients have had a nice big bowel movement the next day after taping; no pain, no fuss.  Regular taping along with strengthening can improve proprioceptive awareness internally (interoception, for those of you who need a new word for the week!)
  4. Transfers and equipment assessment/recommendations.  Therapists can teach your child how to get on/off, up and down safely from a toilet or potty seat.  They can teach you what to say and do to practice transfers and how to guard them while they practice.  They can also take a look at what you already own and what you might need to obtain.  Children with significant motor issues may need an adaptive toileting seat, but most mildly to moderately low-toned kids do not need that level of support.  What they do need is safe and correctly-sized equipment.
  5. Proprioceptive awareness for balance and stability.  Some therapists use balance discs or boards, some use other equipment.  Swings, climbing, jumping, etc.  More body awareness= more independence.
  6. Sensory tolerance for the feeling of clothing, using wipes/TP, the smells and the small enclosure of a bathroom.  If your child has sensory sensitivity issues in daily life, you have to know that they are going to be issues with toilet training.
  7. Effective vestibular processing.  Children that have to turn around, bend and look down then behind their bodies to get TP or pull up their pants need efficient vestibular systems.  Vestibular processing isn’t just for walking and sitting at a table for school.
  8. Practicing working as a team and following directions.  Your child needs to be responsive to either your praise, your rewards or both.  Therapists that support independence (all of us!) and develop in your child the sense that the she is a part of the therapy plan will make it easier for your child to work with you on toileting!

 

 My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone is now available at Amazon.com as well as Your Therapy Source ( a terrific site for parents and therapists)  and on my website,  tranquil babies .  Families are telling me that they have made progress in potty training right away after reading my book!

Read The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Help Has Arrived!  to learn how my book will help you and your child move forward today!

 

 

Low Tone and Toilet Training: What You Can Learn From Elimination Communication Theory

Yes, those folks who hold a 6 month-old over the toilet and let her defecate directly into the potty, not into a Pamper.  Elimination Communication (EC) has committed fans, as well as people who think it is both useless and even punishing to kids.  I am not taking sides here, but there is one thing that should get even the skeptics thinking:  a large portion of the developing world deals with babies and elimination this way.  It is very hard to buy a disposable diaper in Nepal, and it is a problem finding water to wash cloth diapers in the Sahara.  I know there are a bunch of parents who roll their eyes whenever EC comes up, but some aspects of the process could help you train your child to use the toilet.  Why not consider what you could learn from EC that will help your child?

CBV06-custom-comfort-potty-d-1

First, parents who practice EC become very very good at anticipating when their kids are going to need the toilet.  Signs such as grunting, flexing the trunk forward, even facial expressions are quickly noted.  If you spend a lot of time watching your child then you probably know some of the signs.  This makes it easier to tell them to sit on the potty when their attempts will actually be successful.  You can also help them connect the physical feelings they are reacting to with language.  Telling them that when they get that feeling in their belly, they need to go use the toilet sounds so obvious to us.  But if you are little, you need help connecting the dots.  If you are little and have learning issues, you need to hear it more often and stated clearly.

Secondly, EC counts on knowing that reflexive intestinal movement happens about 30 minutes after food enters the stomach, and kidneys dump urine into the bladder about 30-45 minutes after a big drink.  Unless your child has digestive issues, this is a good start to create your initial potty schedule plan.  Kids with constipation or slow stomach emptying may take longer, but you already know that you have to work on those issues as well to be successful in toilet training.  Remember, if your child is roaming the house with a sippy cup, it is going to be a lot harder to time a pee break so that they have a full bladder (remember the issue with poor proprioception of pressure in low tone?).  If not, check out  Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!)  Toilet training is a good time to limit drinking to larger amounts at meals and snacks.  This will work for preschool preparation as well.  Most programs would not allow your child to wander with a cup for hygiene reasons, and you are helping them get off the “sippy cup syndrome”, in which children trade bottle chewing for sippy cup slurping.

Think that embracing EC fully will fast-track your kid?  Not necessarily.  In fact, some EC kids struggle to become more separated from a parent as they are not cradled any longer while “making”.  Taking responsibility for their own hygiene and awareness can be harder for some very attached children than if they were using diapers and used them independently.  But EC concepts are something to think about carefully when you are making your plan to help your child with low muscle tone.