Tag Archives: potty training low tone

Teach Kids With EDS and Low Tone: Don’t Hold It In!

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People who have read my blog are aware that I wrote a book on toilet training, The Practical Guide to Toilet Training Your Child With Low Muscle Tone. The issue of kids who “hold it in” didn’t make it into the book, but perhaps it should have. Children that have problems with muscle tone or connective tissue integrity (or both) risk current and future issues with incontinence and UITs if they overstretch their bladder or bowel too far. We teach little girls to wipe front-to-back to prevent UTIs. We need to teach all children to avoid “holding it in” in the same manner that we discourage them from w-sitting.

I am specifically speaking here about kids with Ehlers Danlos Syndrome, Down Syndrome and all the other conditions that create pelvic weakness and muscle control issues. But even if your child has idiopathic low tone, meaning that there is no identified cause, this can still become a problem.

The effects of low tone and poor tissue integrity on toilet training are legion. Many of them are sensory-based, a situation that gets very little acknowledgment from pediatricians. These children simply don’t feel the pressure of their full bladder or even a full rectum with the same intensity or discomfort that other children experience. This is known as poor interoception, a sensory-based issue that is rarely discussed, even by parents and occupational therapists that are well versed in other sensory processing issues.  For more on how sensory problems affect toilet training, see Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!).   Kids that don’t accurately perceive fullness can be “camels” sometimes, holding it in with no urge to go, and have to be reminded to void. It can be more convenient for the busy child to keep playing rather than go to the bathroom, or it can save a shy child from the embarrassment of public bathrooms; she prefers to wait until she returns home to “go”.

This is not a good idea at all! The bladder is a muscle that can be overstretched in the same way the hip muscles loosen in children who “W-sit”. Don’t overstretch muscles and then expect them to work well. The ligaments that support the bladder are subject to the same sensory-based issues that affect other ligaments in the body: once stretched, they don’t bounce back. Holding it in just stretches vulnerable ligaments out.  A weak pelvic floor is nothing to ignore. Ask older women who have had a few pregnancies how that is working out for them.

The stretch receptors in both the abdominal wall and in the bladder wall that should be telling a child with low tone that it is time to tinkle just don’t get enough stretch stimulation to do so when they have been extended too far.

When should you teach a child not to hold it in?  Right from the start.  The time to prevent problems is when a child is developing toileting habits, not when problems have developed.

So….an essential part of toileting education for children is when to head to the bathroom. If your child has low muscle tone or a connective tissue disorder that creates less sensory-based information for them, the easiest solution is a routine or a schedule. They use the bathroom whether they feel they need to or not. The older ones can notice how much they are voiding, and that tells them that they really did need to “go”.   The little ones can be rewarded for good listening.

Understanding that the kidneys will fill up a child’s bladder after a large drink in about 35-45 minutes is helpful. But it can always be time to hit the bathroom after a meal, before leaving the house, or when returning home. As long as it is routine and relatively frequent, it may not matter how a toileting schedule is created. Just make sure that as they grow up, they are told why this is important. A continent child may not believe that this is preventing accidents, but a child who has a history of embarrassing accidents in public may be your best student.

For little girls who are at a higher risk of UTIs, I tell parents to teach wiping after urination as a “pat-pat” rather than the standard recommendation of front-to-back wiping.  Why?  Because children aren’t really good at remember that awkward movement, and even if you are standing right their reminding her, she may just wipe back-to-front because that is easier and more natural.  “Pat-pat” is an easy movement and reduces her risk of fecal contamination.  I cannot tell you I have done hard research on this, but then, I have common sense.  This is the smarter way for her to wipe.  Want more info on wiping?  Check out How To Teach Your Toddler To Wipe “Back There”

The good news in all of this? Perceiving sensory feedback can be improved. There are higher-tech solutions like biofeedback, but children can also become more aware without tech. There are physical therapists that work on pelvic and core control, but some children will do well with junior Kegel practice and some education and building awareness of the internal sensations of fullness and urgency.

Good luck, and please share your best strategies here for other parents!!

If you are interested in purchasing The Practical Guide to Toilet Training Your Child With Low Muscle Tone, please visit my website, tranquil babies and click on “e-book” at the top ribbon. You can also buy it on Amazon and your therapy source. My e-book is designed to truly help parents make progress, not just offer statements like “Don’t push your child” and “Look for signs of readiness”. That doesn’t help anyone! The book has useful readiness checklists and detailed strategies for every stage of training.  I want children to become independent in toileting without all those tears, and for parents to feel good about guiding their kids in this important skill.

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The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

photo-1445800363697-51e91a1edc73  Toilet Training Help Has Arrived!             

My most popular post,  Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!) inspired me to write a manual to help parents with potty training.  There was nothing in books or online that really helped families, just a few lines about being patient and not pushing children….no help at all!

What makes this book so unique?  Media specialists say that you have to be able to explain your product in the time it takes for the average elevator ride.  OK, here is my elevator speech on The Practical Guide to Toilet Training Your Child With Low Muscle Tone:

My book provides a complete explanation of the motor, sensory, and social/emotional effects that low muscle tone has on toilet training.  It does so without being preachy or clinical.  Parents understand whether their child is ready to train, and how to start creating readiness immediately.  They learn how to pick the right potty seat, the right clothes, and how to decide between the “boot camp” or gradual method of training.  A child’s speech delays, defiance or disinterest in potty training are addressed in ways that support families instead of criticizing them.

  • Each readiness quiz helps parents figure out what issues need to be addressed for successful training and reminds them of their child’s strengths.
  • Chapter summaries give a quick review of each section.  Parents decide which chapter they need to read next to get more information.
  • Clinical information is explained in layman’s terminology, so parents don’t have to Google “interoception” to understand the neurology that causes a child not to recognize that they have a full bladder.

Here’s what parents are saying about The Practical Guide”:

The Practical Guide has truly been heaven sent!  Although my globally delayed 5-year old daughter understood the idea of toileting, this skill was certainly not mastered.  Our consultations with Cathy and her guide on how to toilet train have given me the knowledge I’ve needed to understand low tone as a symptom that can be tackled.  Morgan has made visible advances, and I am so encouraged and empowered because I know what piece we need to work on next.  Thank you, Cathy, for writing this book!”      Trish C, mother of Morgan, 5 years old

“I would often say to myself “Cathy has to put all of her accumulated wisdom down into a book”.  I am happy to say-here it is!  You will find no one with more creative and practical  solutions.  Her insights and ideas get the job done!”     Laura D. H., mother of M., 4 years old 

Cathy has been a “go-to’ in every area imaginable, from professional referrals to toilet training.  I can’t say enough positive things about her.  She has been so insightful and helpful on this journey.”  Colleen S. mother of two special needs children

How do you buy my book?  Three ways:  Visit my website  tranquil babies and click on “e-book” at the top of the homepage, Buy it on Amazon.com, or visit your therapy source, a wonderful site for parents and therapists.  Just search for The Practical Guide to Toilet Training Your Child With Low Muscle Tone!

HELP HAS ARRIVED!

 

 

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Kids with low tone benefit significantly from supportive seating for eating, playing, and yes, toileting.  Picking the right training potty can make all the difference for them, and their parents. My new favorites for smaller children (smaller than the average 3-4 year-old) are the Little Colorado Potty Chair and the Fisher Price Custom Comfort Potty seat.  For older or larger children, I suggest that you take a look at my post on using the adult toilet for equipment ideas. Equipment matters, it really does. Why? Let me give you a short review of what potty seats need to provide for children, and why.

Low muscle tone makes children less stable, and when they are using a toilet, they are not sitting/standing passively. For little boys, you also have to consider standing to urinate. Although it can be easier to start teaching a boy to urinate in sitting, it seems to me that it quickly becomes natural and physically easier for all but the most unstable boys to shift to standing. This means that they may need to hold onto the raised seat for stability or hold onto the edge of the vanity cabinet or even a handrail.

 Selecting a potty seat is seating them for action!  They need to be able to sit straight, get on and off independently and safely, and feel stable enough to let go.  The right seat will let them be slightly flexed forward with knees up above their hips a tiny bit.  This allows them to use their abdominal muscles more effectively to perform a gentle Valsalva Maneuver.

This position is the way traditional cultures “make”; they squat and bend forward, increasing the intra-abdominal pressure to help empty their bowels without straining or holding their breath.  Children with low tone almost always have weak abdominal musculature, and can even have poor smooth muscle contraction of the lower intestine.  That slows the timely movement of feces, contributing to constipation and straining.  Have you ever had the indignity and frustration of trying to have a bowel movement in a bedpan?  Enough said.

Learning a new skill, a skill that is not visible and involves both motor, sensory and cognitive abilities, is best done with equipment that fully supports skill development.  Children often have fears, including fears of falling in.  They get frustrated and don’t want to bother to sit when they could be playing.  The list goes on.  Pick well and a child can learn faster and become more independent.  Pick poorly and learning can be slower, more uncomfortable or embarrassing, or convince both of you to just give up for now.  Want your OT or PT to help you decide?  Read Low Tone and Toilet Training: How Can Your Child’s Therapists Help You ?  and see all the things that therapists can do to help you train your child.

Here is a short review of what my favorite seats have to offer:

Fisher Price Custom Comfort Potty Seat

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Pros:

  • This seat delivers a lot of support, with both a high back and armrests.  A child can feel very supported and safe.
  • Kids can use the armrests to re-position themselves independently and get on/off with less or without help.
  • Small size helps the younger or smaller child get their feet flat and have a better sense of their body position.  Even with the ability to raise the seat an inch or two, it is pretty short.
  • All-plastic construction is easy to clean.
  • A splash guard is molded into the bucket for those little boys who need some redirection.
  • Compact size is easier for travel.  Not if you have a Mini Cooper perhaps, but if you have larger car, you will be able to take your child’s comfortable potty with you on trips.  Nothing ruins a good time like accidents or constipation because a child is too anxious or unstable to “go”.

Cons:

  •  this is not one size fits all; the older and wider child could feel cramped or have their knees way too high for good posture or even comfort.  A shallow seat makes it harder for larger boys to aim accurately when peeing, and doesn’t give taller children of both genders enough input through their thighs for postural control.  Imagine sitting on a tiny little seat; you have to work extra hard to stabilize your body.
  • The short curved armrests may be angled too much to help with standing/sitting if a child really needs support.  They are not independent if they need help to get on and off the potty.

Little Colorado Potty Chair

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This natural wood chair looks like what it is: a traditional commode-style potty.  You can get it in a painted version, and I would opt for that, since the extra layers of finish should be the easiest to clean.

Pros:

  • You can get some add-ons that have benefits: a toilet paper holder and a book rack that attach on either side. The TP roll holder gives a child some independence with wiping (as long as they don’t think that rolling it out to the end is a fun game) .  I would think twice about the book rack for a child that struggles to perceive sensation from the bowel or bladder.  Lots of kids like to look at books while waiting, but for some kids any distractions hinder the ability to accurately perceive bladder/bowel information.  Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!)
  • This chair has a wide, straight back and straight armrests for extra stability and support.
  • This chair is higher, wider and deeper than the FP chair above.  For bigger kids or older children who are being trained later due to developmental delays, this is a big help.  It is hundreds of dollars less than the adapted toilet chairs that kids with more severe or multiple delays really need.  Most children with low tone are not going to need that level of stabilization, and getting more support than you need is not helpful, it slows down independence.

Cons:

  • The bucket insert doesn’t have a splash guard.  That means that little boys especially must be positioned well.  Kids with low tone often shift around more than the average toddler, so keep and eye on the position of everything while using this seat.
  • This chair is not travel-friendly, unless you drive an Escalade or a Tahoe.  It is affordable, so if you have a summer home or if you visit relatives regularly, you can pick up a pair and leave one there.

Neither chair plays music when you pee, has characters all over it, or does anything else but let your child sit there in peace, stable and ready to do the deal.  If you truly need those other things, I guess you could sing a potty song and find some stickers.  Hopefully your child will be able to train quickly and then advance to the next level:  using the adult toilet.

If you have a tall toddler, or your child is over 3.5 years of age, you may not have much choice.  The best system for very unsteady kids is shown in this post Low Tone and Toilet Training: Transition to Using The Adult Toilet , and I have also seen people use something call the Squatty Potty footstool for a bit higher support than the Baby Bjorn stool that I love. The area for foot placement is relatively small, so kids that pay no attention to where their feet are might not be ready for this one.  The squatty folks make a foldaway one with a tote bag that you could take when you go out and use discreetly in public toilets.  Genius.

Want more information about toilet training the child with low tone?  I wrote a book for you!  Visit my website tranquil babies and click on the e-book section in the top ribbon. It is also available on Amazon.com and yourtherapysource.com.  This book gives you extensive readiness checklists that help you make a plan, it teaches you how to navigate problems like refusals and fears, and explains why low tone is such an issue with toilet training!