Tag Archives: sensory processing and toilet training

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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Low Tone and Toilet Training: The 4 Types of Training Readiness

When clients ask me if I think their child is ready to potty train, my answer is usually “Maybe”.  There are numerous factors to consider when assessing toilet training readiness if a child has low muscle tone.

Physical Readiness

After about 18 months, most children can keep a diaper dry for an hour or more.  Their sphincter control increases, and their bladder size does too.  Kids with low tone can take a little longer, but without additional neurological issues, by 24 months many of them will be able to achieve this goal to accomplish daytime urinary continence.  Bowel control is usually later, and nighttime control is later still.  Achievement of the OTHER physical readiness skills are less predictable.  These skills include:

  • Sufficient postural control to stay stable on a potty seat or toilet, and when standing to wipe.  Read How To Teach Your Toddler To Wipe “Back There” for more details on learning to wipe.
  • Enough mobility to get to the toilet on time, turn around to flush, and bend to pull up/slide down pants.
  • Adequate strength and coordination to manage clothing and toilet paper/wipes
  • Sensory processing to perceive a full colon or bladder, tolerate clothing movement on the body and tolerating the “sensory surround” of bathroom use.  Yes, the smells, lights and space of a tiny room can be a “thing” for some kids!

You will notice that children need enough skill, not amazing or even good skills.  They just need enough ability to get the job done.

I need to mention that issues such as constipation can derail the best plans.  Kids with low tone are more likely to have this problem than not.   Read my post Constipation and Toilet Training  for some ideas on how to manage this issue and who can help you.  The best time to manage constipation is before you start training.

Cognitive/Communication/Social Readiness

The trifecta for toilet training readiness in typical children is a child who is at the 16-20 month cognitive/communication/social level.  This child has the ability to follow simple routines and directions, can understand and communicate the need to use the toilet and their basic concerns, and is interested in learning a skill that adults are guiding and praising.

What about children with global developmental delays?  They absolutely can be toilet trained.  I have worked with children who have no verbal skills and perform tasks like dressing and self-feeding only by being prompted, but they can use the toilet.  Do they always know when to “go”, or do they simply follow a schedule?  Well, to be honest, sometimes they toilet on a schedule for quite a while before they connect the physical impulse with the action by themselves.  But they are dry all day.  The essential abilities are these:  they know what they need to do when they sit on the potty, and they know that they are being praised or rewarded in some other way for that action.  That’s it.  Have faith; children with developmental delays can do this!!

Some children with low tone have no delays in any of these areas, but many have delays in one or more.  The most difficult situation with cognitive/communication or social readiness?  A child who has developed a pattern of defiance or avoidance, and is more committed to resisting parental directions than working together.  Toddlers are notoriously defiant at times, but some will spend all their energy defying any directive, must have everything their way or else, and can even enjoy being dependent.

If this is your child, job #1 is to turn this ship around.  Toilet training will never succeed if it is a battle of wills.  And no adult wants it that way.  Repair this relationship before you train, and both of you will be happier.  Read my posts on the Happiest Toddler on the Block methods for ideas on how to use “Gossiping” Let Your Toddler Hear You Gossiping (About Him!)and  Turn Around Toddler Defiance Using “Feed the Meter” Strategies to build a more cooperative relationship with your child.

Family Readiness

Research suggests to me that the number one indicator for training is when the parents are ready.  Sounds off, right?  But if the family isn’t really ready, it isn’t likely to work.  I worked with a family that had their first 3 children in rural Russia.  Boiling dirty diapers on a wood stove makes you ready ASAP!  Families need the time to train, time to observe voiding/elimination patterns and to identify rewards that work for their child.  They need to be prepared to be calm, not angry, when accidents happen and to avoid harsh punishments when a child’s intentional avoidance creates an accident.  They have to be ready to respond to fears and defiance, and then handle the new independence that could bring a child freedom from diapers but more insistence on control in other areas.  Many of my clients have nannies, and most parents have partners. Every adult that is part of the training process has to be in agreement about how to train.  Even if they are more cheerleader than “chief potty coach”, it is either a team effort or it is going to be a confusing and slower process.  Check out Toilet Training Has It’s (Seen and Unseen) Costs for more information about how the process of training has  demands on you that are not always obvious.

Equipment Readiness

Do you have a stable and comfortable potty seat or toilet insert?  How will your child get on and off safely?  Do you need a bench or a stair-like device?  Grab bars?  Do you have wipes or thick TP? Enough clothing that is easy to manage?  Underwear or pull-ups that also do the job?  One of my clients just texted me that having a mirror in front of her daughter seemed to help her manage her clothing more independently.   A few weeks ago we placed the potty seat against a wall and in the corner of the room so that if she sat down too fast or hit the edge of the seat with her legs while backing up or standing, it wouldn’t tip and scare her.  No rugs or mats around, so she won’t have to deal with uneven or changing surfaces as she gets to the potty.  Really think out the whole experience for safety, simplicity, and focus.  If you want to learn what your occupational and physical therapists know about these things, ask them Low Tone and Toilet Training: How Can Your Child’s Therapists Help You ?

You can see why parents rarely get a simple answer when they ask me if their child is ready to train.  I will say that since they are asking the question, they may be ready, and that is one of the four types of readiness!

Do you want more details on toilet training readiness?  

The Practical Guide to Toilet Training Your Child With Low Muscle Tone, is available as an e-book on my website, tranquil babies, on Amazon.com,  or at Your Therapy Source ( a terrific site for parents and therapists!).  If you want more guidance to evaluate your child’s toilet training readiness and learn how to prepare them well, this is your book!  It includes readiness checklists and very specific strategies to build readiness.  Think you are ready to jump in and start training?  My book will guide you to choose between the gradual and the “boot camp” approach, and it addresses the most common stumbling blocks children experience on the road to independence.

Read my post The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Help Has Arrived! , to learn more about this unique book and see what it can do for you today!

Toilet Training Strategies for Children With Autism and Sensory Processing Issues

These strategies have worked for a wide range of children on the spectrum and/or those with sensory processing issues.  Every child is different, but the following techniques are the best I know for most families:

  • Time potty time about 20-30 minutes after meals and snacks.  The act of digestion and drinking should stimulate urination and bowel movements, and you might get results whether or not your child can respond to subtle sensations.  You can then work backward, and help your child connect the event with the sensation.
  • Know your toddler.  Most parents can easily identify when their child is ready to have a bowel movement by their expression or posture.  Some children duck behind the couch or stand in a corner.  Signs of urination are often more subtle, but wiggling while sitting or standing is a common one.  That’s the time to announce a trip to the bathroom!
  • What goes in on schedule will come out on schedule!   Avoid constant drinking throughout the day while training, and switch to only drinking at meals and during scheduled “drink breaks” through the day.  The goal is for you to be able to anticipate when his bladder will be full, and then have him use the toilet successfully 20-30 minutes later.  Connecting the sensation of having a full bladder and the experience of urination is easier this way.   This may be a big change for the child who carries around a covered cup and sips all day long, but once he is trained, you can go back to the “sippy life” if you wish.
  • Make sure that you have a plan, whatever it is, and know why you are doing it that way.  If you have a nanny or daycare provider, make sure that they know your plan and your rationale for it.  Children do best when they sense your confidence and support.  That doesn’t mean you cannot adjust things, but if you are just tossing new ideas out there every few days, it can be very hard for a sensitive child or one with limited modulation to handle all that change.
  • If your older toddler really struggles with control issues, and you suspect that they are resisting toilet training to establish their control rather than just struggling to learn a skill, then you need to address this first.  Establishing limits and building communication skills so that you are teaching more than begging is almost essential.  I suggest the Happiest Toddler methods to develop a strong alliance with you, based on mutual respect and cooperation.
  • Do not underestimate good positioning.  Toddlers that seek movement constantly, fear falling, or  those with a lack of stability all need to get their feet steady on either a stool or on the floor.  Some children with sensory issues can use the little rings over a standard potty, but it is more common for children with SPD to need more support.  They may not tell you they need it, they may just want to get off, not want you to leave them, or refuse to even hop up there.
  • If your toddler is often overexcitable or under-responsive to sensory input, he may have poor state modulation.  Your occupational therapist should be able to tell you if that is an issue for your child.  A nervous system that is idling too slowly isn’t registering the sensations of a full bladder.  The children that are overexcited will be paying attention to just about anything else.  Either way, use the techniques that work to create a more modulated state.  The Wilbarger Protocol, the How Does Your Engine Run activities, and more can help your child regulate their sensory arousal so that they can accurately perceive what is happening.

Remember:  independent toileting is a skill, and your child will develop this skill.  Think of all the skills they have acquired in the past few years.  This is the next one!

Sensory Processing Issues And Toilet Training Your Toddler: The Overview

Toilet training is never fun.  At it’s best, a sweetly cooperative child quickly connects urges with actions, and parents deal with an occasional accident.  In a few short weeks or months, you feel free to go anywhere without extra clothes, creme, wipes and diapers. Not when a child has difficulty processing sensory information.  Sensory processing difficulties do not prevent toilet training; they just make the training process much more complex.  The solution is to know what the typical toilet training strategies are, identify where your child needs more support, and create an environment that supports your unique toddler. Sound familiar?  If you have a child with SPD (Sensory Processing Disorder) or who has sensory processing issues related to developmental delays such as Down syndrome or Autistic Spectrum Disorder, your life is a series of these compromises and adjustments.

First things first:  know what the typical learning pattern looks like, so that your expectations can be reasonable.  “The Baby Whisperer Solves All Your Problems ” is my best resource book for a road map of toilet training through the whole toddler period.  I don’t know too many young toddlers with SPD that have finished training as early as her target age period, but it is helpful to know what she thinks signals readiness.  She also gives excellent studies of training gone wrong, with solutions, so that you feel that both of you can follow any mistakes with eventual success.

Secondly, you need to understand how your child’s sensory issues impact his learning.  Children with poor discrimination and relative insensitivity simply will not register the subtle physical sensations inside their bladder or the wetness in their diaper as strongly as other children.  They truthfully tell you they don’t have (any awareness of the need) to go.  Children who are very sensitive to touch may be very upset at being soiled and could find soggy or loose training pants very unsettling.  They may withhold just to avoid that sensation ever again.  Toddlers with poor postural control may be scared or even actually be unsafe on a loose seat placed over a standard toilet.  How could an adult  “let it go” after climbing up to a 4 foot high seat without no foot support and nothing but a removable ring to grip?  Poor modulators can get overwhelmed with the excitement of success, and poor auditory processing renders encouragement as confusing and stimulating but not instructive. Use all the techniques that have helped your child in the past.  Routines that create calmness, familiarity, and comfort, deep pressure or vestibular activities to stay alert and focused, and techniques that increase their general body awareness will help.  Develop a vocabulary around toileting so that they can explain their experience and can understand what your goals are. And timing.  Toddlers that are tired, agitated, or hungry are your worst students.  Toddlers that have had major scheduling or caregiver changes are stressed already.  Life is complex; you may have to create a calmer and more focused period to start training.

Next Blog Entry:  Specific Toilet Training Strategies for the Toddler with Autism and/or Sensory Issues