If your special needs child isn’t experiencing a medical reason for incontinence (infection, blockage, neurological impairment) then you might be facing one of these three common roadblocks to total training success:
Your child has limited or incomplete interoceptive awareness. What is interoception? It is the ability to sense and interpret internal cues. The distention of the bladder, the fullness of the colon, etc are all internal cues that should send them to the potty. Unfortunately, just as poor proprioception can hinder a child’s ability to move smoothly, poor interception can result in potty accidents, among other things. Working with them to become more aware of those feelings can include monitoring their intake and elimination routines. You will know when they should have more sensory input, and can educate them about what that means. Listen to how they describe internal feelings. Kids don’t always know the right words, so use their words or give them a new vocabulary to help them communicate.
Your child’s clothing is difficult to manage, or their dressing skills aren’t up to the task. They run out of time before nature calls. Tops that are hard to roll up, pants that have tricky fasteners, even fabrics that are hard to grasp and manipulate. All of these can make it a few seconds too long once they get into the bathroom. If you are not in there with them, you may have to ask them to do a “dry run” so you can see what is going on and what you can change to make undressing faster. In my e-book, The Practical Guide To Toilet Training Your Child With Low Muscle Tone, I teach parents the best ways to teach dressing skills and the easiest clothing choices for training and beyond. If you have ever had to “go” while in a formal gown or a holiday costume, you know how clothing choices can make it a huge challenge to using the toilet!
Your child is too far from the bathroom when they get the “urge”. Children with mobility problems or planning problems may not think that they are in trouble right away. They might be able to get to the bathroom in time in their own home. When they are out in public or at school, the distance they have to cover can be significant, and barriers such as stairs or elevators can be an issue. Even kids playing outside in their own yards might not be able to come inside in time. If you can’t alter where they are, teach them to use the potty before they go outside or when they are near the bathroom, instead of waiting. Taking the time to empty a half-full bladder is better than an accident.
Is potty training after the toddler years different? Yes, and no. Here is what you need to consider when you are looking at the equipment for an older child that is still in a diaper or a pull-up. Whether they have language or not, whether they have rigid or stereotyped behaviors or not, your set-up when training the older child is very important.
Your child probably won’t fit correctly on a toddler potty seat. Unless your child is significantly shorter and thinner than her peers, she won’t fit. Children that are nonverbal or very compliant may not complain about sitting so low or so tightly. They just won’t do well. They may only sit for a short time, get agitated, or withhold. They may cling to you when transferring on and off because they are sitting so low. It can look like they either don’t understand what to do, or won’t comply. Both can be wrong. The defiant ones will cry and refuse to use a seat that doesn’t fit them. Some crafty parents have adapted the smaller seats for their slim little ones, but not everybody can do that. Look at my posts on the adult toilet Low Tone and Toilet Training: Transition to Using The Adult Toilet or on a child-friendly size Should You Install a Child-Sized Potty for Your Special Needs Child? for help to reconfigure your set-up ,giving your child a better chance at success and comfort.
The right environment for toileting is not in front of the TV. After all these years of using diapers or pull-ups (which is developmentally really a diaper that you wear, not absorbent underwear), using the toilet can seem as silly to them as going into a restaurant and cooking our own dinner would be to us! If you have the room, use the bathroom for training. Bring them into the fold by requiring them to assist you with all aspects of diapering, turn off the TV so you have their attention, and when you do watch potty videos, make sure you are there reminding/encouraging them. Your demonstrated interest has more power than you think!
You are gonna need a bigger boat (wipe). Nod to one of my favorite movies, Jaws. But seriously, using those tiny little toddler wipes from the cute dispenser might not do the job on a 5 year-old heine. Not enough wiping with a tiny one, and if they aren’t clean down there, it is not only messy, it is a hygeine issue. Use the grown-up wipes and put Paw Patrol stickers on it if you have to sell them as appealing.
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?
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!
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.
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.
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?
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. And consider a child-sized toilet in the bathroom they use most Should You Install a Child-Sized Potty for Your Special Needs Child?.
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.